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Mark HL Wilson1, Dr Tom WM Walker2, Prof. Leo FA Stassen3

Author affiliations
1RCSI medical student
2Registrar in Oral & Maxillofacial Surgery, University College Hospital Galway
3Professor of Oral & Maxillofacial Surgery, St James’s Hospital/Dublin Dental School and Hospital

Royal College of Surgeons in Ireland Student Medical Journal 2010; 3: 13-16.

Introduction
Oral and maxillofacial surgery (OMFS) is one of the nine surgical specialties and is unique in that it requires qualifications in both medicine and dentistry. To become a specialty training registrar (StR) or consultant, it is necessary to obtain a fellowship in surgery, and most people will also complete a fellowship in dental surgery or equivalent. Registration with the Irish Medical Council and the Irish Dental Council is required. Despite the long training period, it offers a diverse professional life that is both challenging and rewarding for those who take the leap and return to pursue their second degree towards this specialty.

What do oral and maxillofacial surgeons do?
Oral and maxillofacial surgeons provide a variety of treatments in a well-defined anatomical area – the head and neck. They deal with the diagnosis, evaluation and treatment of conditions arising around the face, jaws, mouth and their environment, including the maxilla, mandible, nose, neck and salivary glands. The scope of the specialty and the management of the pathology encountered ranges from the surgical removal of teeth and facial pain management, to excision and free flap reconstruction of oral-facial malignancy, facial trauma, and cleft lip and palate surgery (Table 1). The wide scope provides the opportunity to treat patients from different age groups and affords a varied and exciting practice. Oral and maxillofacial surgeons ideally work in teams and alongside other specialists including ENT surgeons, plastic surgeons, neurosurgeons, ophthalmologists, orthodontists, restorative dentists, clinical oncologists, radiotherapists and radiation oncologists, and pain specialists.

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Clockwise from top left: FIGURE 1: A 3D reconstructed facial CT demonstrating severe maxillofacial injury. FIGURE 2: An ortho-pantomogram (OPG) of a patient who underwent open reduction and internal fixation. This was to correct a right-sided parasymphyseal fracture of the mandible that had subsequently sustained a second fracture, at his left angle, left condyle and right parasymphysis. Of note, the patient has three impacted wisdom teeth and an impacted upper right canine. FIGURE 3: Squamous cell carcinoma of the right lateral margin of the tongue. FIGURE 4: Right submandibular abscess secondary to a dental cause (impacted wisdom tooth).

History of oral and maxillofacial surgery
World War II saw a large number of young men returning from combat with severe facial injuries. In the United Kingdom and Ireland ‘plastic surgery and jaw injury’ units were established in the Queen Victoria Hospital in East Grinstead, the Ballochmyle Hospital in Ayrshire, Scotland, and later in Dr Steeven’s Hospital in Dublin. In these units, consultant dental surgeons worked with plastic surgeons to reconstruct the faces of those soldiers who returned. Since then, dental surgeons have been increasingly involved in the reconstruction and rehabilitation of the head and neck. Since 1995 it has become compulsory for surgeons to be dually qualified to practice OMFS. OMFS has now established itself as a leader in several fields such as facial and craniofacial trauma, head and neck oncology and its reconstruction (including microvascular surgery), oral surgery and cleft palate/lip repair, and craniofacial surgery (Figures 1-4).

Training
There are currently two routes to become an oral and maxillofacial surgeon (Figures 5-7). One option is to complete medicine as a first degree, then return to dental school after completing basic surgical training (BST) and the MRCS exam or an equivalent. In the UK, some trainees return to dental school after their two-year foundation programme (equivalent to intern and SHO 1 years). Irish medical graduates are at an advantage to finance themselves and pursue their interest in the specialty during their dental degree with BST/MRCS. It might be advantageous to obtain a year as an SHO in OMFS in the UK or Ireland before starting dental school to gain firsthand experience in the specialty. Some dental schools either offer a shortened degree (three to four years) or offer graduate dental programmes as in the UK. After completing a dental degree, trainees with OMFS experience should apply for a surgical training three (ST3) post in OMFS and aim to complete their postgraduate dental membership examinations (MFDS/MJDF) during ST3 or ST4 year. It is important to ensure eligibility to apply for any Irish training scheme or ST3 (SpR1 in the UK). Most often, applicants are considered ineligible because of inadequate proof of completion of foundation competencies, which are available on the Internet and can be verified.
Those who complete undergraduate dental training as a primary degree can then return to medical school after gaining a broad- based dental, oral surgery and basic OMFS experience. This can be achieved within two years of qualifying as a dentist, usually accompanied by sitting the postgraduate dental examinations and obtaining the Membership of the Faculty of Dental Surgery at one of the royal colleges (e.g., MFD/MFDS/MJDF or equivalent). Some medical schools now offer a three-year course specifically for dental graduates or a four-year graduate entry course. After a year of internship they apply for the RCSI BST in Ireland, or in core training one (CT1) in OMFS or surgery in general in the UK. Thereafter, they apply for ST3 in OMFS in the UK.

Higher surgical training (specialty training)
Higher surgical training (HST) is five years that is simultaneously taken with the intercollegiate FRCS (three to five years). Unfortunately, HST in OMFS was lost from Ireland in early 2000 and there is currently no HST in OMFS. However, it is hoped that a HST programme will be available by 2010. Training in OMFS is currently available in the UK, Europe, the USA and Australia. In the UK the first three years of the specialty training are general and competency based, while the next two years are specialised. The curriculum for HST in the UK and Ireland is available online via the Intercollegiate Surgical Curriculum Programme website (http://www.iscp.ac.uk). Currently, there is a trend towards a post-certificate of completion of training (CCT CST) fellowship in one of the sub-specialties (cleft, head and neck, craniofacial). It is expected that fellowships will become available in trauma and aesthetics in the near future (Figures 5-7).

FIGURE 5: Sequence of training pathways in oral and maxillofacial surgery. Click to see image.

FIGURE 6: Training pathway for oral and maxillofacial surgery in Ireland. Click to see image.

FIGURE 7: Training pathway for oral and maxillofacial surgery in the United Kingdom.1 Click to see image.

Oral and maxillofacial services in Ireland
Over the last 20 years, OMFS has established itself as an important and accessible hospital service in many countries worldwide. Unfortunately, Ireland lags behind. A statutory government body, Comhairle na nOspidéal, which is now part of the HSE, stated in a report released in 2005 that oral and maxillofacial services in the Republic of Ireland had developed slowly and were largely underdeveloped in comparison to international standards.2 The report cited understaffing at consultant level as the main factor for deficient service provision. Some of the key recommendations outlined by the report were to increase consultant numbers from six to 24 posts in the long term, develop academic posts in OMFS, and to regain recognition for training in OMFS in Ireland as a priority. Since 2003, four new oral and maxillofacial surgeons have been appointed in Ireland in the public hospitals and continued expansion at the consultant level is expected, with two posts advertised in the near future.

Conclusion
OMFS offers diverse scope of practice in a specialty that is heavily dependent on surgical treatment of conditions. It offers the skills of dentistry and surgery in modifying the facial skeleton, managing dental occlusion, and reconstructing and rehabilitating the oral cavity. It is this balance of hard and soft tissue practice, as well as the broad range of congenital and acquired conditions, which present themselves to oral and maxillofacial surgeons. It makes for a demanding and rewarding career, working closely with other medical, dental and surgical specialties, as well as with allied health professionals.

Further advice and links
British Association of Oral & Maxillofacial Surgeons – www.baoms.org.uk
Association of British Academic Oral & Maxillofacial Surgeons – www.abaoms.org.uk
Intercollegiate Surgical Curriculum Programme – www.iscp.ac.uk
Post Graduate Medical Education & Training Board Report on OMFS Training – www.pmetb.org.uk/index.php?id=omfs

References

  1. Intercollegiate Surgical Curriculum Programme. Oral and maxillofacial surgery: the training pathway. Cited September 1, 2009. Available from: http://www.iscp.ac.uk/Syllabus/ Overview.aspx?Spec=OMF2.
  2. Comhairle na nOspidéal. Oral & Maxillofacial Surgery Services, June 2005. Cited September 1, 2009. Available from: http://www.lenus.ie/hse/handle/10147/44533.

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