Oral and maxillofacial surgery

Anatomy or system affected: Gums, head, mouth, teeth

Definition: A specialty of dentistry that deals with the diagnosis and management of diseases or conditions of the mouth, teeth, jaws, and face.

Science and Profession

The specialist in oral and maxillofacial surgery deals with the anatomical region of the head that includes the oral cavity and the hard and soft tissues that compose that part of the facial skeleton formed by the mandible and the maxilla. The mandible is the bone that forms the lower jaw, and the maxilla is the fusion of the two bones that form the middle part of the face, or the upper jaw.

The maxilla forms the roof of the mouth, the lateral walls and floor of the nose, and the floor of the eye cavities. The maxilla contains the maxillary sinuses and holds the upper teeth. The mandible holds the lower teeth and attaches to the temporal bone of the skull at the temporomandibular joint (TMJ).

The diseases and conditions treated by oral and maxillofacial surgeons are numerous and diverse. They may include extraction of impacted teeth, dental implants, benign and malignant lesions of the oral cavity, TMJ disorders, management of facial pain syndromes, facial fractures, obstructive sleep apnea, and surgical correction of congenital deformities. Oral and maxillofacial surgeons will treat infections of the jaws, oral cavities, and salivary glands and may perform facial cosmetic procedures.

Most oral and maxillofacial surgeons begin their training after dental school. Increasingly, medical doctors are being integrated into the specialty through additional dentistry training and subsequent entry into an oral and maxillofacial training program. The oral and maxillofacial surgical residency includes general surgery, plastic surgery, medicine, and anesthesia. A four-year residency program grants a degree that makes these surgeons board eligible in oral and maxillofacial surgery. Some American oral and maxillofacial surgeons complete a six-year residency program that grants a medical degree as well. Graduates of the residency program may elect to pursue additional fellowship training in head and neck cancer, cosmetic facial surgery, pediatric maxillofacial surgery, or maxillofacial trauma.

Oral and maxillofacial surgery is recognized as a dental specialty. The American Board of Oral and Maxillofacial Surgery is responsible for certifying oral and maxillofacial surgeons in the United States. The board is recognized and approved by the Council on Dental Education of the American Dental Association. To become board certified, a typical applicant will have completed four years of undergraduate studies and four years of dental school, followed by an approved training program. Candidates must present letters of recommendation from board-certified oral and maxillofacial surgeons and then pass a written and oral examination. After completion of these qualifications, applicants are granted the title of diplomat of the American Board of Oral and Maxillofacial Surgery. The board requires that its diplomats be recertified every ten years.

Diagnostic and Treatment Techniques

Oral and maxillofacial surgeons take careful and detailed histories of present and past medical conditions, including family history, medication history, and allergy history. Examination of the oral and maxillofacial area includes a complete examination of the oral cavity and the use of radiologic techniques to visualize the soft tissues and bone structure of the jaw and the mid-face. Many oral and maxillofacial surgeons perform conventional radiographs (X-rays) and panoramic radiographs of the upper and lower jaw in their office. The diagnosis of oral and maxillofacial conditions is further aided by diagnostic images from computed tomography (CT) scans and magnetic resonance imaging (MRI).

Oral and maxillofacial surgeons perform surgical procedures both at the hospital and in the office. Because many biopsies and dental procedures are done in the office, these specialists must be proficient in administering oral sedation, local anesthetics, nitrous oxide, intravenous sedation, and general anesthesia. Patients who come to oral and maxillofacial surgeons come from all age groups. They may have multiple medical conditions and require a broad range of medical and surgical care. The oral and maxillofacial surgeon must be part medical doctor, part general surgeon, and part dentist.

Some of the more common treatment techniques in oral and maxillofacial surgery include dental procedures for removal of impacted teeth or teeth that cannot be restored. These surgeons may work along with restorative dentists to reconstruct bone for placement of dental implants. In the event of facial trauma, oral and maxillofacial surgeons may be called upon to repair routine and complex fractures, repair lacerations, and reconstruct damaged nerves and blood vessels. Oral and maxillofacial surgeons may diagnose and treat benign cysts and growths in the oral cavity, including cysts that form in the salivary glands. Head and neck cancer diagnosis and treatment may include malignant lesions of the jaws, lips, or oral cavity.

A major component of the specialty involves reconstructive and orthognathic surgery to correct congenital deformities, such as facial asymmetry, bite deformities, and cleft lip or palate. Obstructive sleep apnea is being increasingly recognized; severe cases may be life threatening and may be an indication for surgical intervention by an oral and maxillofacial specialist. Maxillomandibular advancement surgery may be performed in selected cases. The procedure involves moving the upper and lower jaws forward. The bones are surgically separated and advanced to increase the opening of the airway. The procedure is done in the hospital under general anesthesia and may take three to four hours to complete. In cases of severe obstructive sleep apnea that do not respond to conservative treatments, this type of orthognathic surgery may be the treatment of choice.

Chronic facial pain disorders that oral and maxillofacial surgeons deal with include TMJ disease and neurogenic pain syndromes. TMJ disorders may cause pain in the ear, headache, or pain when moving the jaw. The oral and maxillofacial surgeon may treat this condition conservatively with medication or splint therapy. In more severe cases, open or arthroscopic joint surgery may be indicated. The most common craniofacial pain syndrome is trigeminal neuralgia. If medications are not effective, then the oral and maxillofacial surgeon may treat this condition with local nerve block, surgical destruction of the nerve, or microvascular decompression of the trigeminal nerve root.

Because of their surgical training, their familiarity with the soft tissue and structural anatomy of the face, and their experience with office-based surgery and anesthesia, oral maxillofacial surgeons are uniquely qualified and positioned to take advantage of developments in facial cosmetic surgery. Facial cosmetic surgery may be indicated for birth defects, deformity resulting from injury, or aging process reversal. Facial plastic surgery that may be performed by the oral and maxillofacial surgeon includes cheekbone implants, chin augmentation, facial and neck liposuction, lip enhancement, and face-lift surgery. These specialists may also use the surgical laser to remove outer layers of damaged skin, inject collagen to fill wrinkles, and use Botox injections to reduce muscle activity that causes wrinkles.

Perspective and Prospects

Hesy-Re, an Egyptian scribe who lived around 2600 BCE, is credited as the first dentist. The Greek physician Hippocrates, who lived between 500 and 300 BCE, described treatments of diseased teeth and gums, including the use of forceps to extract teeth and wires to stabilize fractured jaws. During the early part of the Middle Ages, most oral surgery was performed by monks; after the popes forbade monks from practicing medicine, barbers became responsible for extracting teeth and draining dental abscesses. In 1723, the French surgeon Pierre Fauchard described the practice of dentistry, including oral anatomy and operative and restorative procedures; he is credited with being the founder of modern dentistry. The American Revolutionary War figure Paul Revere advertised himself as a dentist, in addition to being a fine silversmith. The first dental school was established in 1840 as the Baltimore College of Dental Surgery, and in 1867 the Harvard Dental School became the first university-affiliated dental school. In 1844, the Connecticut dentist Horace Wells performed the first dental extractions done using nitrous oxide as an anesthetic.

Simon P. Hullihen of Wheeling, West Virginia, both a medical doctor and a dentist, is considered the founder of oral surgery. He specialized in operations on defects of the mouth and head and performed hundreds of operations for cleft lip, cleft palate, and other abnormalities of the mouth and jaw.

Another contributing factor to the development of the specialty of oral and maxillofacial surgery was the devastating injuries suffered by soldiers during the great wars of the twentieth century. It became clear to battlefield surgeons that dentists were needed to help align dental occlusion in facial injuries and fractured jaws. Dentists became valued members of the surgical team and remains the field from which most oral and maxillofacial surgeons come.

In 1945, a committee was authorized to establish an American Board of Oral Surgery (ABOS). In 1947, the ABOS was approved by the American Dental Association. The name of the board was changed to the American Board of Oral and Maxillofacial Surgery in 1978 to reflect the complete scope of the specialty.

Advancements in cosmetic and reconstructive surgery put the oral and maxillofacial surgery specialist at the cutting edge of medical innovation. An example is the French oral and maxillofacial surgeon Bernard Devauchelle, who along with his colleagues at the University Hospital Center of Amiens, France, performed the first human face transplant. In November 2005, Devauchelle and his team transplanted the central and lower face of a thirty-eight-year-old woman whose nose, lips, and chin were lost to a dog bite. Their success was reported around the world and hailed as a milestone in surgical history. By the early 2020s, the science had advanced even further. Reconstructive surgery was aided by stem cells, ENDORET plasma, bone morphogenetic protein, and same day implant placement. The specialty of oral maxillofacial surgery in the twenty-first century is a dynamic field that attracts both medical and dental school graduates. Although the residency program is long and arduous, the rewards of the specialty are great.

Bibliography

Coulthard, Paul and Giles McCracken. Master Dentistry. 4th ed., Elsevier, 2022.

Ellis, Edward, et al. Contemporary Oral and Maxillofacial Surgery. 7th ed., Elsevier, 2020.

Meneghini, Fabio, and Paolo Biondi. Clinical Facial Analysis: Elements, Principles, and Techniques. Springer, 2012.

Miloro, Michael, et al. Peterson’s Principles of Oral and Maxillofacial Surgery. 4th ed., Springer, 2022.

Mitchell, David A. An Introduction to Oral and Maxillofacial Surgery. 2nd ed., CRC Press, 2017.

White, R. L. “Oral and Maxillofacial Surgery: Defining Our Present, Shaping Our Future.” Journal of the American College of Dentistry, vol. 76, no. 1, 2009, pp. 36–39.