Oral and maxillofacial surgery is a dental specialty that performs surgery on the teeth, jaws, mouth, and surrounding structures in the head and neck. In order to become an oral and maxillofacial surgeon in the United States, a student must complete four years of dental school. They will then proceed into a four to six year residency in a hospital based setting. Often the six year residency program will also confer the degree MD, or doctor of medicine. In this case, the person would be both a medical doctor and a dentist. Oral and maxillofacial surgeons can pursue additional training in specialties such as cleft lip/palate and craniofacial surgeries, facial cosmetics, and head and neck cancer (American Student Dental Association). The American Board of Oral and Maxillofacial Surgery offers the designation of board certified once a candidate has passed a written qualifying examination and an oral certifying examination. The written qualifying examination consists of 300 questions. The oral certifying examination consists of four 50-minute sections to test a candidate’s knowledge and judgment in the field. Once a candidate becomes board certified, they must maintain certification on a ten-year cycle. During that cycle, they must register with the board annually, complete 90 hours of continuing education credits every three years, have an evaluation of performance practice, and pass the certifying exam again (American Board of Oral and Maxillofacial Surgery). To become an oral and maxillofacial surgeon in the UK, candidates are required to attend and pass both medical school and dental school, in addition to surgical training (British Medical Journal Careers).
History of oral and maxillofacial surgery
The history of oral and maxillofacial surgery starts with a history of dentistry itself. The ancient civilization Sumer, located in the Fertile Crescent of the Middle East (particularly in the area occupied by the Tigris and Euphrates Rivers of modern day Iraq), believed that tooth decay occurred because of tooth worms, according to an ancient text dated 5000 BCE (American Dental Association).
Hesy-Re (lived around 2650 BCE, unknown dates of birth or death)
Hesy-Re was a high ranking Egyptian official during the reign of Djoser. His tomb was discovered in the late 1860s, but was not completely excavated until 1910-1912 by British Egyptologist James Quibell. Inside the tomb were several panels which were used by the Egyptians as a method to preserve the existence of the deceased into the next life and to give the offerings needed to achieve this. These panels listed Hesy-Re as Chief of Dentists and Physicians, the first known person to hold the title of dentistry as it related to surgery. Examination of mummies from ancient Egypt has revealed that dental disease such as worn teeth, gum disease from bacterial build up in the gum line, and dental abscesses were common among all social classes, suggesting there was a need for dentistry among the population. However, there are few instances where it appears that dental surgery was performed in those mummies examined thus far. Papyrus scrolls have been found detailing medical ways to stabilize loose teeth and help dental abscesses, though understanding of the causes of these diseases was lacking (Forshaw, 2015).
Artzney Buchlein
The Artzney Buchlein was the first book to be written completely on dentistry. It was published in Germany in 1530 by an anonymous author. The book was written for barbers (who also performed tooth extractions during the Middle Ages) and surgeons (who performed more extensive oral surgery). It details drilling teeth, placement of gold fillings, tooth extraction, and oral hygiene (American Dental Association).
Ambroise Paré (1510-1590)
Ambroise Paré was a French barber-surgeon who is considered one of the fathers of modern surgery. At that time, barber-surgeons performed surgery but were held in lower esteem than physicians, who did not perform surgery. Paré spent most of his career working on the battlefield on wounded soldiers and working on the poor during times of peace. He challenged the conventional wisdom of the time and made advances in several areas of surgery, not just oral and maxillofacial surgery (Hernigou, 2013). Paré published a collection of his works on surgery and dentistry in 1575 in Paris, which included advice on performing a tooth extraction, treating dental decay, and repairing jaw fractures (American Dental Association).
Pierre Fauchard (1678-1761)
Fauchard was a French dentist best known for his publication of the textbook The Surgeon Dentist or Treatise on the Teeth in Paris in 1728. He is widely regarded as one of the fathers of modern dentistry. Fauchard trained in the French Navy under a surgeon who was also particularly interested in diseases of the mouth. Upon leaving the Navy, he started working as a dentist. At the time, there was no formal education requirements for practicing dentistry and no governing body for dentists. Fauchard read widely and also studied other crafts which would help him in his practice: watch-making, jewelry-making, and enameling. At this time in history, most patients had to rely on tooth pullers for any type of dental or oral surgery needs they had. Tooth pullers worked in markets or fairs. A few patients could afford to have a surgeon with an interest in teeth perform their care. Fauchard established an excellent reputation in his practice and was the first to refer to himself as a “surgeon dentist.” At the time, knowledge of the trade was kept secret and jealously guarded. Fauchard established an openness for sharing knowledge with his two volume book, where he shared all of his observations and practices with students and colleagues alike. In the book, he dismissed the longstanding notion that tooth decay was caused by tooth worms and instead coined the term dental decay. He made observations about orthodontics (he is also considered one of the first to practice orthodontics), oral surgery, anatomy, pathology and pharmacology. Because of Fauchard, France became known as a leading center of dental excellence. The Pierre Fauchard Academy was established in 1936, whose objectives include recognizing superior dentists, sharing of knowledge among colleagues, mentorship programs, and scholarships for dental training (Lynch, 2006).
Paul Revere (1734-1818)
The same Paul Revere who is famous for his midnight ride to warn the American colonists that the British were coming was also a practicing dentist. He learned dentistry from John Baker, who had immigrated to the Americas from England. Paul Revere fitted a dental prosthetic for his friend, Dr. Joseph Warren, who was a major general among the American rebel forces against the British. When Dr. Warren was killed at the Battle of Bunker Hill, he was buried in an unmarked grave. Dr. Warren’s family wanted his body returned for a proper burial, but the grave was on land controlled by the British for another nine months. Once the land was returned to the colonists’ control, Raul Revere located the grave and was able to identify the decomposing body based on the prosthetic he himself had fashioned. This was the first instance of the military using dental records to identify a body, termed a forensic dental identification (Nola, 2016).
Simon P. Hullihen (1810-1857)
Simon P. Hullihen was an American dental surgeon who is credited with the creation of the orthognathic branch of oral and maxillofacial surgery. He has also been called one of the fathers of oral surgery. Hullihen was most widely known for an operation on a young woman who had suffered a severe burn to the face and neck at five years of age. The extensive scar tissue formed a web like structure which caused her to be unable to turn her head, caused her jaws to grow out of alignment, and made it where her chin was tucked toward her chest all the time. Hullihen corrected it in three different surgeries in an era prior to the discovery of antibiotics and prior to the use of anesthesia (the patient was given something for pain). Hullihen was also very well known for his treatment of cleft palate. He eventually established the first hospital dental unit at the Wheeling Hospital in Wheeling, Virginia (Aziz, 2004).
William T.G. Morton (1819-1868)
William Morton was an American dentist who was the first to publicly demonstrate the use of ether as an anesthetic for surgeries, including dental procedures. Another American dentist, Horace Wells, had attempted the same feat the year before, but it was considered a failure because the patient cried out in pain. A medical doctor, Crawford Long, later claimed that he had successfully used ether anesthesia two years earlier, but had not yet published his findings (American Dental Association).
James Edmund Garretson (1825-1895)
James Edward Garretson was an American oral surgeon who helped established oral and maxillofacial surgery as its own specialty in the United States, separate from general surgery, by introducing oral surgery as a formal part of the dentistry curriculum at Philadelphia Dental College. He was the first appointed professor of oral surgery while teaching there. He is also known his authoritative textbook, A System of Oral Surgery, published in 1869. He named the new specialty. For this, he is considered a father of oral surgery (Lew, 2013).
Fluoridation: Frederick S. McKay (1874-1959) and H. Trendley Dean (1893-1962)
Frederick S. McKay was an American dentist who is known for his research on fluoridation of water. McKay completed his dental training in Pennsylvania and moved to Colorado Springs, Colorado, where he found that an unusual number of people had permanently stained mottled brown teeth. None of his colleagues seemed concerned with the problem, so McKay decided to find the cause. He traveled to other areas where people had similar symptoms and deduced that it was likely because of something in the water supply. However, when he tested it, he found nothing outside of the ordinary. An American chemist in Pennsylvania, Dr. H.V. Churchill, read McKay’s publication of his findings and decided to run his own tests, looking at micronutrients. He found that the water had a higher than usual level of fluoride. Dr. McKay noted that people with the brown stains on their teeth were resistant to dental decay (Pierre Fauchard Academy). Dr. H. Trendley Dean, head of the Dental Hygiene unit at the National Institute of Health, began investigating fluoride in 1931. At first, he wanted to find out at what concentration of fluoride the brown mottled teeth would appear and what was the highest safe concentration in water. He eventually discovered that up to 1.0 ppm (parts per million) was safe in drinking water. Dean then wondered whether putting fluoride in drinking water would help prevent tooth decay. In 1945, Grand Rapids, Michigan agreed to fluoridate their water supply so that the population could be studied. Over the 15-year span of the study, dental caries rates among schoolchildren in Grand Rapids dropped by 60% (National Institute of Dental and Craniofacial Research). This groundbreaking research affected the amount of dental surgeries needed by oral and maxillofacial surgeons since there was less need to treat decayed teeth with extraction. This led them to expand their scope of surgeries as well as expand their training (Lew, 2013).
Examples of surgeries performed by oral and maxillofacial surgeons
Dentoaveolar surgeries include difficult tooth extractions, impacted teeth, bone grafting in preparation for dental implants, construction of dentures or other oral prosthetics.
Dental implants are titanium metal cylinders used to replace teeth. They are placed into the jaw bone in such a way that the bone grows around them and locks them in place. The surgery also consists of preparing the treatment site, including reconstruction of bony and soft tissues in the area, as well as maintenance of the area after the surgery (American Association of Oral and Maxillofacial Surgeons).
Wisdom teeth extraction is when an oral surgeon removes the wisdom teeth from the mouth. During the surgery, an incision is made, the tooth is removed (including any bone that is blocking full access to the tooth), the site is cleaned, and stitches may be placed (though this isn’t always necessary) (Mayo Clinic).
Correction of maxillofacial skeletal deformities is when the surgeon repositions and contours bones of the face and jaw to correct deformities. Surgery may also include reconstruction of bony areas and tissues. Deformities may be due to birth defects, environmental exposures, developmental problems, trauma, degenerative diseases, or because of cancerous processes (American Association of Oral and Maxillofacial Surgeons).
Cleft lip/palate is a condition in which the hard palate of the top of the mouth does not fuse properly while the baby is inside its mother’s womb. Surgical correction of this condition is usually performed during childhood (American Association of Oral and Maxillofacial Surgeons).
Maxillofacial trauma is trauma to the face, head and neck. Repair can include setting fractured bones, reconnecting nerves that have been cut during the injury, and reconnecting ducts (such as tear ducts or salivary ducts) that were cut during the injury (American Association of Oral and Maxillofacial Surgeons).
Temporal mandibular joint disorders are disorders that occur where the jaw bone meets the rest of the face. Oral and maxillofacial surgeons can help with both the surgical and non-surgical management of these disorders (American Association of Oral and Maxillofacial Surgeons).
Oral and maxillofacial surgeons perform reconstruction of the face, nose, mouth, and neck after other surgeries to remove diseased areas, such as cysts, infections, and cancers of the mouth and salivary glands. The goal with these surgeries is to return the patient to their best appearance and function following surgeries to remove disease (American Association of Oral and Maxillofacial Surgeons).
Orthognathic surgery is surgery specific to correction of developmental abnormalities of the jaw and facial bones which affect chewing, speech and overall health because it can affect the appearance of the face itself. These types of problems often show themselves as malocclusion of the jaw. Surgery is often done in conjunction with orthodontic treatment (American Association of Oral and Maxillofacial Surgeons).
Cosmetic surgery is also performed by oral and maxillofacial surgeons for various patient requests. This can include rhinoplasty (restructuring of the nose), brow lifts, cheek lifts, cheek augmentation, and lip enhancement (American Association of Oral and Maxillofacial Surgeons).
Surgical treatment of obstructive sleep apnea, a condition that causes poor sleep due to the patient experiencing apneas (short periods when the patient stops breathing), is also done by oral and maxillofacial surgeons. While a CPAP mask is often prescribed for this, some people are unable to tolerate the mask and prefer surgery (American Association of Oral and Maxillofacial Surgery).
Current research in oral and maxillofacial surgery
Massachusetts General Hospital has several research projects underway in the department of oral and maxillofacial surgery. One study is examining the effects of cannabis on orthodontic tooth movement in rats. They will be looking specifically at how cannabis affects bone remodeling, the rate of closure between teeth using an orthodontic device, and rate of root absorption (Massachusetts General Hospital).
Researchers at the University of Pennsylvania are investigating the reasons for the development of osteonecrosis of the jaw (bone death in the jaw) caused by a class of medication called bisphosphonates. This class of medication is used to prevent weakening of bones (osteoporosis). There is currently no treatment or cure for osteonecrosis of the jaw caused by bisphosphonates. Researchers there are also investigating what changes on the cellular level cause oral cancers so that new therapies may be developed to target those (Penn Medicine).
There are ongoing research projects at Boston University investigating treatment of jaw bone fractures in HIV positive patients, quality of life outcomes after orthognathic surgery, success of implants into grafted bone, gunshot injuries to the face, and infections of the head and neck due to dental problems (Boston University School of Dental Medicine).
The University of Tennessee has ongoing research in oral cancers and their relation to human papilloma virus (HPV) (University of Tennessee).
Presbyterian Hospital/Weill Cornell School of Medicine faculty has brought about new surgical techniques for doing a minimally invasive temporomandibular joint arthroscopy. This technique has no incisions, no stitches, and is usually performed in an outpatient facility so general anesthesia is not needed. This allows for quicker recovery for patients. The procedure also allows surgeons to visualize and treat the cause for the disorder. The procedure has a high success rate and is considered a cost effective alternative to more invasive surgeries. For patients with more advanced disease that will require a joint replacement, the jaw prosthesis is custom made and fitted for the patient’s specific anatomy. This type of procedure is performed in the operating room of the hospital (Weill Cornell Medical College).
The National Institute of Dental and Craniofacial Research is conducting trials on three different medications being considered for pain relief after wisdom tooth extraction. Their website lists studies that are in all stages from recruitment to completion, with topics as diverse as the autoimmune disorder Sjogren’s syndrome (which causes underproduction of saliva); the relationship between oral bacteria, autoimmune diseases, and gum disease; biomarkers for oral cancer; different types of medications to treat facial pain; how HIV affects the oral cavity; what exactly makes up dental plaque; the role of interaction between members of a couple and health behaviors; the role of parent-child interactions and health behaviors; whether probiotics play a role in oral health; the effectiveness of different types of pain medications for dental procedures; predicting the risk of tooth decay in certain populations (e.g., low socioeconomic status, different ethnicities, people with developmental delays); and many others. The National Institute of Dental and Craniofacial Research also supports National Institute of Health student loan repayment programs for interested and qualified individuals. It provides opportunities for high school, undergraduate college student, graduate student, dental student, and medical student involvement in research in their labs. Postdoctoral fellowships for students who have already earned a PhD, MD or DDS are also available. Funding may be obtained for clinical trials via grant for qualified applicants (National Institute of Dental and Craniofacial Research).
Oral and maxillofacial surgery is constantly changing to help patients with disorders of the jaws, mouth, and face. Current debates about whether it is necessary to get both a medical degree and a dental degree continue. Regardless, the specialty has shown itself resilient in learning new treatments and expanding the scope of practice.
Forshaw, R. (n.d.). HesyRe: The First Recorded Physician and Dental Surgeon in History . Bulletin of the John Rylands University Library of Manchester,89(Supplement), 181-202.
Lynch, C. D., O'Sullivan, V. R., & McGillycuddy, C. T. (2006). Pierre Fauchard: the 'Father of Modern Dentistry'. British Dental Journal,201, 779-781. doi:10.1038/sj.bdj.4814350
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