How to become an oral and maxillofacial surgeon

Why a medical and dental degree?

The modern maxillofacial surgeon evolved from the hospital dental service. At the inception of the NHS, hospital dentists provided care for inpatients and outpatients who were compromised such that dental treatment was best performed in a hospital setting. As the early NHS developed, so too did the range of services that hospital dentists provided. This was because of dentists' unique anatomical understanding and knowledge of jaw pathology. This development continued until it became clear that dentists' lack of a medical degree was hampering the delivery of a comprehensive service. Dentists with a passion to encourage further development of the specialty obtained a medical degree. Since then, having a dual qualification was seen as the norm to progress. The name of the specialty has changed alongside this evolution: from hospital dentist to oral surgeon to maxillofacial surgeon, in line with the service provided.

Consequently, maxillofacial surgeons no longer provided many aspects of dental care in addition to their surgical workload. Consequently, specialist dental surgeons—such as restorative dentists and prosthodontists—are often found working in maxillofacial units to provide specialist advice as required—for example, in cleft clinics and head and neck oncology clinics.

Although the specialty evolved most in the past three to four decades, dual qualification began with Simon P Hullihen (1810-57) in the 19th century. Modern maxillofacial surgeons continue to acknowledge the benefit of both degrees.

Unlike dentistry, the five year undergraduate medical degree does not test operative ability and manual dexterity. By contrast, possession of a BDS or BChD degree shows that a graduate is manually dextrous and competent in handling minor surgical procedures to a satisfactory degree.

Career path (^*four years and one year in the subspecialty)

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Subsequent to the European Specialist Medical Qualification Order (1995) it is now mandatory that a doctor must be a registered medical and dental practitioner in order to be eligible for inclusion in the specialist register for oral and maxillofacial surgery. This register is held by the General Medical Council.

Most trainees in maxillofacial surgery start from a dental background, but the number of medics pursuing a maxillofacial career and gaining a dental degree has risen greatly in recent years.

Qualities needed to become a successful maxillofacial surgeon

To read two undergraduate degrees, applicants need to have mental stamina, persistence, and dedication, but this is really no different from any other surgical specialty. Maxillofacial training is often considered long and arduous, but comparison with other surgical specialties (notably, plastic surgery and general surgery) shows that consultants in these specialties are typically appointed at similar ages. This reflects the different “bottlenecks” in training programmes and the apparent “necessity” to obtain further degrees to get ahead. The first degree in either medicine or dentistry typically takes five years. The second degree can take anything from three to five years, depending on the entry policy of the individual medical or dental school. Concessions may be obtained for higher qualifications such as MRCS or MFDS.

Rolands with radiotherapy mask. Portrait: Mark Gilbert

Credit: FACIAL SURGERY RESEARCH FOUNDATION

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How long will it take?

After qualifying, dentists tend to complete a year of general professional training and then take up a post in oral and maxillofacial surgery before returning to medical school. Similarly, medics will complete their two foundation years before returning to dental school.

After acquiring both degrees and completing foundation training, trainees can move into higher surgical training. Candidates need to be eligibile to sit the MFDS (member of the Faculty of Dental Surgery) and the MRCS (member of the Royal College of Surgeons) diplomas, one or other of which may be obtained earlier during the second undergraduate degree. As for all surgical specialties, the MRCS diploma is a prerequisite to obtain a training number. Although the MFDS diploma can be obtained during the course of specialist training, gaining it before starting is advisable.

After foundation training, specialty training will take four years, and the candidate acquires a certificate of completion of training (CCT) at the end. An additional year or two at a regional or international centre may be undertaken to subspecialise.

For academic minded trainees, a proportion of time may be spent in research, leading to a PhD, MS, or MD. This is not mandatory for entry into specialist training.

Attractions of maxillofacial surgery

With the new consultant contract, the working week for a surgeon is planned on the basis of a certain number of “programmed activities” each week.

One such activity is four hours in the working week but three hours in premium time (at weekends and after 7 pm). Most trusts appoint surgeons on the basis of at least 10 programmed activities per week to start with, and the arrangement is usually reviewed annually.

A typical working week is likely to include:

• Outpatient clinics (three programmed activities: one special and two general clinics);

• Operating lists (three to four programmed activities: one day surgery list and one all day list);

• Teaching (one programmed activity);

• Administration (one programmed activity); and

• On-call commitment (one programmed activity).

This is, of course, variable and depends on local arrangements.

Like most surgeons, within maxillofacial surgery consultants have areas of special interest as well as providing a general maxillofacial service. The main special interest areas include:

• Head and neck oncology, including reconstruction;

• Adult facial deformity—orthognathic surgery;

• Cleft surgery; and

• Facial trauma management.

Working life is enjoyable as the on-call commitment is not too onerous, and those who are interested have ample scope for private practice.

Currently, the United Kingdom has 313 consultant posts and 121 specialist registrar posts. There are vacancies, and quick succession through the ranks is possible. The box shows the wide scope of this specialty.

Interdisciplinary relations

Working relationships with other specialties are close, such as ear, nose, and throat surgery and plastic surgery; clinical oncology and radiotherapy; accident and emergency medicine; and dermatology. ■