Oral and Maxillofacial Surgical Procedures

By Sally Robertson, B.Sc.

Oral and maxillofacial pathology is a branch of dental science concerned with diseases, injuries, abnormalities and cancers of the mouth, jaws and face. Oro and maxillofacial (OMF) surgeries are procedures performed in the treatment of these disorders and diseases.

The OMF speciality has been recognized by several organizations and professional associations including the American Dental Association, the Royal College of Surgeons of Edinburgh, the Royal College of Surgeons of England and the Royal Australasian College of Dental Surgeons.

Specialized training

Dentists who decide to become an OMF surgeon have a basic degree in dentistry followed by several years of core training that is specific to OMF surgery. To practice as an OMF surgeon, a joint qualification in dentistry and medicine is required and the profession is often viewed as a bridge between these two disciplines, with skills and expertise required from both backgrounds. The surgeons apply this combined knowledge in the treatment of conditions such as salivary gland disease, facial pain, impacted teeth, head and neck cancers, jaw cysts or tumors and many other problems involving the oral mucosa such as infections and ulcers. In many cases, the OMF surgeon focuses on one or more of these areas to develop sup-specialist interests within the more general scope of the speciality.

Sub-specialities

The main sub-specialist areas that OMF surgeons practice are described in more detail below.

Head and Neck Cancer

Orofacial cancer is fatal if left untreated. It usually begins with a rough patch, lump or ulcer that develops on the tongue, floor of the mouth or lip. These lesions have a tendency to spread to the lymph nodes in the neck. However, many of these cancers remain in a pre-malignant state before they become invasive and the patient may be cured if surgical excision is performed and risk factors are controlled in the early stages.

For those with suspected malignant disease, practitioners are now required to refer these patients to an OMF surgeon with expertise in malignant disease of the head and neck within fourteen days. It may be possible to treat some patients presenting with small and easily accessible lesions using radiotherapy. However, patients usually require surgical resection of the tumor, followed by reconstructive surgery and rehabilitation.

Orthognathic surgery

Orthognathic surgery translates literally as “surgery to create straight jaws.” To achieve this, a technique referred to as osteotomy is usually performed, which involves cutting parts of the jaw to create removable fragments of bone that can be repositioned to form a straight jaw.

The most common indications for osteotomy are difficulty eating or biting due to malocclusion, facial deformity, speech abnormality and poor dental appearance.

Craniofacial surgery

This area is concerned with conditions that affect hard and soft tissue in the face and head. Some examples of craniofacial conditions include the following:

• Craniosynostoses – The premature closing of one or more of the joints that lie between the bones in a baby’s skull
• Craniofacial dysotosis syndromes – A group of conditions characterized by abnormality of the face, skull and sometimes the limbs. Usually, the problem is fused coronal sutures in the skull, which cause the skull to form in a tall, wide shape.
• Encephalocoeles – A neural tube defect where pouch-like protrusions extend from the brain and push through openings in the skull.
• Cranio-facial clefts – a large group of defects that affect the face and cranium, ranging from cleft lip and palate to extensive clefts that cause significant malformation.

All of these conditions develop early on in life and patients are usually children under the age of 2. Treatment involves a multidisciplinary team that combines neurosurgery and maxillofacial reconstruction. This surgery is major and is associated with significant blood loss and intensive care is often required for complex cases or when breathing is compromised.

Dentalalveolar surgery

This refers to the surgical treatment of problems involving the teeth and the supporting tissue that surrounds them. Examples of the procedures performed include the following

• Surgical removal of teeth due to decay, fracture or problems with the surrounding bone
• Removal of impacted teeth, usually wisdom teeth or canine teeth
• Removal of cysts in the jaw
• Tooth transplantation, where a buried or impacted tooth may be removed and repositioned to fill a gap created by a lost tooth.
• Pre-orthodontic surgery - aside from removing impacted teeth, these teeth can also be exposed through surgical removal of the overlying gum tissue or bone.
• Pre-prosthetic surgery, which refers to procedures to construct or improve the function of dentures.
• Dental implants, which are titanium root forms that are used to fill areas where teeth are missing to support a crown, denture or bridge.

Oral medicine

Disorders of the oral mucosa are common and can be categorized into four main groups which include ulcers, blistering, sore mouth and red and white patches. The most commonly occurring type of oral mucosal disorder is recurrent oral ulceration, which affects around 10 to 15 % of people, usually while they are young. The majority of these ulceration disorders are minor aphthous ulceration, which presents with small, flat ulcers and these heal within two weeks of surgical removal, without any scarring occurring. The remainder of the ulcers are major aphthous ulcers, which are larger and deeper ulcers that take up to six weeks to heal after removal and also form scar tissue.

Trauma

Examples of trauma to the head, neck and face range from simple injuries such as small cuts or loose teeth through to complex injuries involving the nerves or brain.

OMF surgeons manage such injuries in a variety of settings and may be found practising in an emergency services setting or on the battlefield, for example, where they provide services to the military. The healthcare they provide ranges from simple would cleaning through to complicated craniofacial reconstruction. For particularly severe injuries, the OMF surgeon make work closely with experts from various other fields such as neurology or ophthalmology.

Facial aesthetics

This field is included as part of the training for more advanced OMF surgical trainees, with these individuals having extensive skills and knowledge regarding the anatomy, growth, development and function of the face and jaw, as well as the inter-relationships between all of these components. Some of the most common procedures performed in facial aesthetics include the following:

• Rhinoplasty to adjust the size or shape of the nose and nasal function
• Genioplasty to address chin deformity
• Pinnaplasty to adjust a problem referred to as “bat ears”
• Procedures to improve problems caused by ageing skin include forehead lift; blepharoplasty to remove “eye bags;” cheiloplasty to reshape the lips and rhytidectomy, which is a face lift.

Jaw joint problems

Jaw joint problems are common, affecting as much as 40% of people at some stage in their lives, although these problems are m re common among females. Pain and clicking in the joints usually begins in adolescence, but this usually resolves and does not recur. In a small group of people, the problem continues into early adult life before the symptoms resolve. For a very small proportion of individuals, the problems continue and eventually causes chronic pain and discomfort.

Temporomandibular joint problems generally fall into two groups – those where the anatomy is normal but function is not, and those where the anatomy is abnormal and function may or may not be normal. For the first group, the first therapeutic measure taken is usually conservative such as exercise, diet changes, medication to reduce muscle spasms and anxiety and alteration of the dental bite. In around 50% of patients these measures are enough to resolve the problem. For the second group however, problems arising due to disorders of the bone itself such as arthritis or problems with soft cartilage tissue may require surgical treatment. These surgeries are often complex and are only carried out after comprehensive conservative treatment has failed to work. These procedures range from restoration of the meniscus through to adjustment of the joint anatomy and surgery to replace joints.

Further Reading

• All Maxillofacial Content
• Maxillofacial Injuries
• Oral and Maxillofacial Pathologies