Maxillofacial surgery

A brief history

The roots of oral and maxillofacial surgery lie in the world wars, when service personnel sustained devastating facial injuries. With experience it became clear that the key to successfully fixing a fractured jaw was correctly re-establishing the dental occlusion, and so dentists were employed as members of the surgical team. Historically, therefore, consultants in oral and maxillofacial surgery were dental graduates. However, as the scope of the specialty increased, it became inevitable that a medical qualification was also needed. Today, oral and maxillofacial surgery consultants must be qualified in medicine and dentistry.

What do they do?

Oral and maxillofacial surgery is the surgical specialty associated with the diagnosis and treatment of diseases of the mouth, jaws, face, and neck. It is an eclectic specialty that involves the management of head and neck cancer, facial trauma and deformity, and salivary gland and oral pathology. “From cranialising the frontal sinus to freezing the inferior alveolar nerve, from osteotomising the upper jaw to dissecting the neck bilaterally, from surgically removing a wisdom tooth to reconstructing the tongue, this specialty offers it all,” says Montey Garg, a dentally qualified senior house officer in oral and maxillofacial surgery at the John Radcliffe Hospital in Oxford. Oral and maxillofacial surgery doesn’t stop at the clavicles, says Daljit Dhariwal, consultant in oral and maxillofacial surgery at the John Radcliffe Hospital: “We don’t just work around the face but we also take distant flaps of tissue to reconstruct faces so we use a variety of techniques and perform operations all over the body.”

Because the range of diseases treated by oral and maxillofacial surgeons is broad, so are the different types of patients who present to the department. “We treat all ages, from children to elderly people, and we are often treating patients who have multiple comorbidities, so there’s a lot of general medicine involved,” explains Dhariwal.

A typical week

Dhariwal’s typical week involves a variety of ward rounds, theatre lists, and outpatient clinics. Like many oral and maxillofacial units, Oxford is a hub, providing a service to several peripheral hospitals. Her typical working week therefore includes clinics in Reading and Banbury, where she also does an operating list of day cases. “Because we have a hub and spoke working system we do lots of interesting cases at the core centre and then we do the majority of the straightforward routine things out in the peripheries. It means you’re able to provide local care to those that need it, but you’re also able to pool all the specialist knowledge into one area. I think when you are working in such a department it gives you the opportunity to subspecialise and to continue to develop services in your own areas of interest.” She attends multidisciplinary specialist clinics in orthognathic surgery (surgery to create “straight jaws”) and craniofacial surgery (for patients with congenital and acquired craniofacial deformities) as well as general clinics. She also has weekly commitments to teaching and clinical governance. Once every six weeks, Dhariwal is the consultant on call for the department. These weeks are often hectic, caring for patients who have facial trauma often as a result of interpersonal violence and road traffic crashes. When on call you never know quite what’s coming next. Being called to a resuscitation in the emergency department to assess a patient with polytrauma and operating late into the night alongside other surgical teams are common.

The training pathway

Oral and maxillofacial surgery is the only surgical specialty that requires dual qualification in medicine and dentistry. Most oral and maxillofacial consultants studied dentistry and then medicine as a second degree, however, with the rising number of accelerated dental degrees for graduates and doctors, a rising number of medics achieve dual training.

Most people’s first taste of working in an oral and maxillofacial unit is either as a dentally qualified senior house officer or as a medically qualified second foundation year doctor. Jerry Raju, second foundation year doctor at the John Radcliffe Hospital, says, “Like any other surgical junior job our main responsibilities are to manage perioperative patients. Management of patients with head and neck cancer can be particularly challenging, and this provides good training in a critical care environment. We also get a lot of experience in theatre and suturing lacerations in the emergency department, which is a great way of developing basic surgical skills.” If you decide that this specialty is for you, you must achieve dual qualification before starting specialist training.

Pluses and minuses

A common theme when asking oral and maxillofacial surgeons why they love what they do is that working on the head and neck is rewarding. Dhariwal explained, “Everybody’s face is important, and we have to have an appreciation of body form and body image. Our face is how we identify ourselves to the world or to ourselves in the mirror. I think the psychology of working in the head and neck area means that you need to have an appreciation for what that means to the patient—it’s really important. One of the nicest bits is that patients are incredibly grateful because of this. They’re very appreciative, more so I think than in a lot of other areas of medicine.”

Raju believes that there are advantages of a maxillofacial surgery placement as part of foundation programme training. “Before I started my F2 job I hadn’t had much exposure to the specialty and this applies to most of my medically qualified friends. Having done the job now I’ve been pleasantly surprised by how much it has to offer. It is a great specialty for hands-on surgical experience. There is a diverse case load, ranging from purely dental work to complex head and neck cancer surgery. This job provides generic, transferable skills.”

Some people say that the possible downside of a career in oral and maxillofacial surgery is the lengthy training. This often puts people off pursuing a career in oral and maxillofacial surgery but Dhariwal doesn’t think it should. “If you compare it with other similar surgical specialties, such as neurosurgery or cardiothoracic surgery, then the training time from the time you start to when you become a consultant isn’t actually any longer. In other specialties you often need to get higher degrees to get ahead, and in oral and maxillofacial surgery you don’t necessarily need to do that. Although you need the second degree to gain the additional clinical skills that are required to progress, I see that as a plus point because you’re gaining skills that you wouldn’t have if you didn’t have the second degree. In terms of what happens to you at the end of training, the ratio of trainees finishing and getting a certificate of completion of training number to getting a consultant post is almost one to one, so once you’ve finished your training you’re almost guaranteed a job, which is unusual compared with other surgical specialties.”

Is it for me?

Garg says that “a good maxillofacial surgeon needs to be a combination of a general surgeon, a plastic surgeon, an orthopaedic surgeon, a vascular surgeon, an oncosurgeon, a doctor, and a dentist.” This is quite daunting, but according to Raju is what makes the specialty “varied and exciting.”

If you have a love of surgery and medicine and an interest in working in the head and neck area then this might be the specialty for you. The best way to find out is to get some experience of working in an oral and maxillofacial surgery unit, either as a medical student or during your foundation training. Dhariwal says, “I think most oral and maxillofacial surgery units would welcome interest from medical students regardless of whether they wish to pursue a career in the specialty or not. I’d encourage any medical student to contact a unit near them if they were interested in finding out more. There are potential opportunities for research projects, audits, or case reports if you’re linked with a unit.”