Resources and Surgical Services

What is Oral and Maxillofacial Surgery?

Maxillofacial and Oral Surgery is a specialty of Dentistry that involves the diagnosis and treatment of diseases, deformities and trauma of the mouth, jaw and face.

Oral and Maxillofacial surgery involves the removal of difficult or impacted teeth, the placement of dental implants, the management of facial injuries and infections, the treatment of dental and skeletal deformities, as well as the treatment of pathological and aesthetic correction in the Maxillofacial area.

Who Are Oral and Maxillofacial Surgeons?

Oral and Maxillofacial Surgeons (OMFS) are uniquely trained to manage the diagnosis, surgical and medical treatment of diseases, as well as traumatic injuries and deformities of the mouth and facial region. OMFS are trained to correct the results of birth defects and accidents, tumours, missing and impacted teeth and malfunction of the jaw joints. To make procedures more comfortable for patients, various methods of sedation are available to patients, including local anaesthesia, intravenous conscious sedation, and general anaesthesia.

OMFS are dental specialists who are surgically trained in hospital-based residency programs and work with medical residents in numerous different medical specialities to gain comprehensive knowledge. This knowledge is focused on the mouth, jaw, face, muscles of the face, bone, and skin.

What Health Care Procedures can OMFS Provide?

Oral & Maxilliofacial Surgery

Implants

Dental Extractions

Facial Trauma

Wisdom Tooth Removal

Jaw Surgery

TMJ

Biopsy

Anaesthesia

Dentistry, and specifically Oral and Maxillofacial Surgery, has made significant contributions to the art and science of anaesthesia. Horace Wells, an American Dentist, is often quoted as being the discoverer of anesthesiology. Horace Wells discovered the benefits of nitrous oxide, or laughing gas, which continues to be used today in both medicine and dentistry.

Many patients do not look forward to a trip to the dentist’s office, and even fewer look forward to having a tooth removed. Due to these fears, necessary treatment is often delayed or ignored. The Oral and Maxillofacial Surgeon has received extensive training in the areas of pain and anxiety control. These measures will usually include local anaesthesia, or “freezing”. For longer or more complicated procedures, various methods can also be used to help keep patients comfortable. These techniques can involve the administration of sedative drugs through oral, inhalational or intravenous routes. Intravenous sedation is often employed and is usually accomplished through the administration of one or more drugs that will produce a calm and relaxed state. While patients may be aware of their surroundings, they are generally relaxed and in many cases will not remember the procedure itself. Intravenous anaesthesia involves the administration of several medications with the aim of producing a state of total unawareness.

In order to safely provide such advanced care, We, as Oral and Maxillofacial Surgeons have received specific training throughout their career. Their offices are usually a little different from a general dentist’s as they need to have extra equipment in order to safely provide anaesthesia services. In many cases, the offices will resemble a hospital operating room. Additionally, the staff will also include registered nurses who will provide assistance during and after your procedure. Each province in Canada has specific guidelines that Oral and Maxillofacial Surgeons must follow in order to provide such care in their offices, and many provinces issue a site permit that signifies compliance with these regulations.

Your surgeon will thoroughly discuss your anesthetic management prior to your procedure, and will review the risks and benefits of each approach. Rest assured, it is our goal to provide a safe and comfortable experience.

Surgery of the Oral Cavity & Wisdom Teeth

Impacted Wisdom Teeth

The removal of impacted wisdom teeth is best suited for the expert training of the Oral and Maxillofacial Surgeon.

Wisdom teeth often begin erupting in the mouth between the ages of 15 to 25. Everyone has a different growth rate, which explains why each person may have wisdom teeth removed at slightly different ages.

Wisdom teeth are the last molars to erupt within the mouth. Most often, there isn’t enough room in the mouth for these teeth. Because of the lack of space, the wisdom teeth often become mal-aligned. These mal-aligned wisdom teeth can cause pain, pressure, infection and damage to the adjacent molars. Sometimes these problems can occur without having any prior signs or symptoms.

A special (panoramic) radiograph taken of the jaw is best and recommended to see the condition of the wisdom teeth.

There are usually four wisdom teeth in total, and each one may be partially erupted, erupted inside the mouth, or still located under the gum or bone tissue. The tooth still located under the gum or bone tissue is known as an impacted tooth.

Most of Oral and Maxillofacial Surgeon will often recommend the removal of wisdom teeth in a young adult. This is because the risks involved with the removal of wisdom teeth greatly increase with age. This is also the case with the recovery period: the older one is, the longer the recovery period tends to be.

At the initial consultation appointment with your Oral and Maxillofacial Surgeon, the appropriate post-extraction care instructions will be explained in detail. The risks, complications and normal post-extraction course of action will also be well explained. Following all of the post-extraction care instructions is key to ensuring a fast and proper recovery.

Other Dentoalveolar Procedures

The expertise of the Oral and Maxillofacial Surgery is also required for procedures such as:

  • Bone grafting and soft tissue grafting to improve future implant sites in the jaws.
  • Placement of dental implants.
  • Biopsy of a suspicious area, or of a lesion found on the gums or in the jaw bone.
  • Surgical exposure of impacted teeth, other than wisdom teeth, so that with the help of the orthodontist, these teeth can be pulled into proper alignment within the mouth.
  • Removal of infections at the root ends of teeth with chronic infections (apicoectomy or apectomy).
  • The surgical treatment to help a denture fit properly (pre-prosthetic surgery)
  • The surgical removal of bone outgrowths that may occur in both upper and lower jaws (removal of tori and exostosis)
Dental Implants
  • Dental implants are designed to provide a foundation for replacement teeth which look, feel, and function like natural teeth. The person who has lost teeth regains the ability to eat virtually anything and can smile with confidence, knowing that teeth appear natural and that facial contours will be preserved. The implants themselves are tiny titanium posts which are placed into the jawbone where teeth are missing. The bone bonds with the titanium, creating a strong foundation for artificial teeth. In addition, implants can help preserve facial structure, preventing the bone deterioration which occurs when teeth are missing.
  • Dental implants are changing the way people live! With them, people are rediscovering the comfort and confidence to eat, speak, laugh and enjoy life.
  • Oral and Maxillofacial Surgeon has received extensive training in implantology and has been successfully placing implants for years. Through continuing education, your surgeon is kept abreast of the most current information on implant dentistry.
  • Evaluation
  • If, like many others, you feel implant dentistry is the choice for you, we ask that you undergo a dental/radiographic examination and health history. During these consultation visits, your specific needs and considerations will be addressed by your surgeon. Your questions and concerns are important to us and our team will work with you very closely to help make your procedure a success.
  • There are many types of insurance plans, and coverage for implants is varied. Your surgeon will be happy to assist you in obtaining any benefits to which you may be entitled.
  • Procedure
  • Dental implants are metal anchors which act as tooth root substitutes. They are surgically placed into the jaw bone. Small posts are then attached to the implants which protrude through the gums. These posts provide stable anchors for artificial replacement teeth.
  • For most patients, the placement of dental implants involves two surgical procedures. First, implants are placed within your jawbone. For the first three to six months following surgery, the implants are beneath the surface of the gums, gradually bonding with the jawbone. You should be able to wear temporary dentures and eat a soft diet during this time. At the same time, your restorative dentist designs the final bridgework or denture, which will ultimately improve both function and aesthetics.
  • After the implant has bonded to the jawbone, the second phase begins. We will uncover the implants and attach a small healing collar. After two weeks, your restorative dentist will be able to start making your new teeth. An impression must be taken, then posts or attachments can be connected to the implants. The teeth replacements are then made over the posts or attachments. The entire procedure usually takes six to eight months. Most patients do not experience any disruption in their daily life.
Joint Disorders

Temporomandibular joint disorders are common, affecting 25% to 30% of the population. They consist of a group of conditions that cause pain or dysfunction in the jaw joints and chewing muscles. Other problems may include limited mouth opening, jaw locking and clicking in the jaw joint. This group of conditions also includes a number of arthritic conditions that can affect the jaw joint.

Oral and Maxillofacial Surgeons are specifically trained in diagnosing and treating these conditions.

The diagnosis is based on the clinical examination and review of the patient’s history.  Sometimes imaging studies like x-rays, MRI scan or CT scan are indicated.

The management of these conditions usually involves a variety of simple treatments that can include medications, physiotherapy and bitesplint therapy. These simple measures help the overwhelming majority of patients.

A small percentage of patients with TMD can benefit from surgical treatment by the Oral and Maxillofacial Surgeon. There are a variety of surgical treatments that can be considered, including injection of medication into the joint or muscles, and washing out the joint.

Arthroscopic surgery is a minimally invasive procedure carried out in hospital on an out-patient basis. A tiny operating telescope (2.3 mm in diameter) is inserted into the joint. A video picture allows direct examination inside the joint. A variety of miniaturized surgical instruments can be inserted to perform clean-out and repair procedures. Some patients will ultimately benefit from open surgery on the joint for repair or replacement of the disc, or even replacement of the entire joint. Joint replacement with either the patient’s own bone grafts or artificial total joint replacements can be very helpful for patients who have had severe or destructive disease affecting the jaw joint.

Pathology & Reconstruction

Oral and Maxillofacial Surgeons are a surgical specialists with expertise in the mouth, face and jaws. In addition, some Oral and Maxillofacial Surgeons undergo additional complex head and neck, and microvascular surgical training to offer patients comprehensive jaw and face reconstruction, and oral rehabilitation care.

Many patients may undergo initial screening through their dentist, family physician or other dental and medical specialist prior to being referred to an Oral and Maxillofacial Surgeon.  Referral to an Oral and Maxillofacial Surgeon can be for identification and proper diagnosis of any abnormal soft or hard tissue finding in the region of the mouth, jaw, face or neck. After an initial clinical assessment with a surgeon there may be a need for further investigation, including, but not limited to:

  • Special imaging: x-rays, panorex, CT scans, MRI, PET or bone scans
  • Further screening tests: endoscopy, light amplification to identify tissue abnormalities (ex. Velscope) and brush biopsies (similar to Pap tests)
  • Surgical biopsy with partial or complete removal to help identify the lesion/abnormality

Oral and Maxillofacial Surgeons have extensive training covering a vast array of disease processes that affect the oral cavity and surrounding structures, such as:

Soft Tissue Abnormalities which in the mouth, can be due to irritation, reaction to certain drugs and materials in the mouth, be an evidence of a vitamin or mineral deficiency, or represent an underlying infection.

Soft Tissue Tumours may represent abnormal growths of various origins, which can often be removed entirely.

Bone Cysts which are fluid filled sacs within the bone which can be decompressed, or removed entirely.

Bone Tumors are abnormal growths within bone that are caused by abnormal development of the bone, teeth or tooth related tissues. Treatment can vary from conservative removal, or removal with surrounding structures.

Skin Cancers – basal cell, squamous cell, and melanoma cancers are the most common types. Surgeons provide removal and can often provide simultaneous reconstruction to make affected tissue area appear as natural as possible.

Oral Cancer – which is most often squamous cell carcinoma. Oral cancer is largely caused by cigarette smoking, viruses and other environmental factors. Surgical removal is frequently the recommended treatment, often with combined removal of the lymph nodes. Reconstruction of the defect is frequently indicated to restore oral and facial form and function.

Other Head and Neck Malignancies are invasive lesions in the cancer spectrum that can involve various tissues, including bone and saliva glands. Treatment often requires surgical removal and possible reconstruction as appropriate.

 Reconstruction

Oral and Maxillofacial Surgeons are capable of providing reconstructive care that encompasses restoration of both form and function. The blend of backgrounds covering dentistry, medicine, and head and neck surgery offers a complete understanding of all facial components. By using various techniques from simple closure to complicated tissue transfers, the jaws and facial anatomy can be reconfigured with a cosmetic, natural appearance, and provide a proper functioning bite. For reconstructive purposes, soft tissues (skin, mucosa, fat, muscle) and hard tissues (bone, cartilage) can be taken from various parts of a patient’s own body based on necessary size and shape, or can be utilized from donated or engineered tissues, or growth factors.

Oral and Maxillofacial Surgeons can accordingly diagnose, surgically treat and repair all aspects of your oral and facial condition. In certain cases, referral to an Oral and Maxillofacial Surgeon with sub-specialty or fellowship training in a unique discipline may be required. Canadian Oral and Maxillofacial Surgeons are often using state of the art technology with computerized surgical planning, custom prosthesis design, robotics, and patient specific rehabilitation. As such, your Oral Maxillofacial Surgeon can provide optimal goal directed care for complex needs.

Facial Trauma

Craniomaxillofacial Trauma

Should you or a family member/friend ever experience trauma to the face or mouth that requires a trip to the emergency room, or an immediate visit to your doctor/dentist, it is possible that you will require the services of an Oral and Maxillofacial Surgeon (OMFS). Oral and Maxillofacial Surgeons are trained, skilled and uniquely qualified to manage and treat Facial Trauma. An OMFS is on staff at a local hospital and provides emergency room coverage for facial injuries including:

  • Facial lacerations
  • Intra oral lacerations
  • Fractured facial bones (cheek, nose, or eye socket)
  • Fractured jaws (upper and lower jaw)

Injuries to the face, by their very nature, impart a high degree of emotional as well as physical trauma to patients. The science and art of treating these injuries requires special training involving a “hands-on” experience and an understanding of how the treatment provided will influence the patient’s long term function and appearance.

The Nature of Maxillofacial Trauma

There are a number of possible causes of facial trauma. Motor vehicle accidents, accidental falls, sports injuries, interpersonal violence, dog bites and work-related injuries account for many. Types of facial injuries can range from injuries of teeth, to extremely severe injuries of the skin and bones of the face. Typically, facial injuries are classified as either soft tissue injuries (skin and gums), bone injuries (fractures), or injuries to special regions (such as the eyes, facial nerves or the salivary glands).

Soft Tissue Injuries of the Maxillofacial Region

When soft tissue injuries such as lacerations (cuts) occur on the face, they are repaired by “suturing” (stitches). In addition to the obvious concern of providing a repair which yields the best cosmetic result possible, care is taken to inspect for and treat injuries to structures such as facial nerves, salivary glands and salivary ducts (or outflow channels). Oral and Maxillofacial Surgeons are well trained and proficient at diagnosing and treating facial lacerations as well as intra oral lacerations.

Bone Injuries of the Maxillofacial Region

Fractures of the bones of the face are increasingly common, and may affect the patient’s vision, their ability to breathe, speak, and perhaps even swallow. Bones that are broken in the face, such as the lower jaw, upper jaw, palate, cheekbones, and eye sockets, are treated in a manner similar to the fractures in other parts of the body. Treatment may require hospitalization. The specific form of treatment is determined by various factors which include the location of the fracture, the severity of the fracture, and the age and general health of the patient. When an arm or a leg is fractured, a “cast” is often applied to stabilize the bone and allow for proper healing. Since a cast cannot be placed on the face, other means have been developed to stabilize facial fractures.

Fractures of the jaws are best treated and stabilized by the surgical placement of small “plates and screws” at the involved site. This technique of treatment can often allow for healing and eliminates the need for having the jaws wired together. This technique is called “rigid fixation” of a fracture. The relatively recent development and use of “rigid fixation” has profoundly improved the recovery period for many patients by allowing them to return to normal function more quickly.

The treatment of facial fractures should be accomplished in a thorough and predictable manner. Most importantly, the patient’s facial appearance should be minimally affected. An attempt at accessing the facial bones through the fewest incisions necessary is always made. At the same time, the incisions that become necessary are designed to be small and, whenever possible, are placed so that the resultant scar is “hidden”.

The proper treatment of facial injuries is now in the realm of specialists well versed in the emergency care, acute treatment and long-term reconstruction and rehabilitation of the patient. An Oral and Maxillofacial Surgeon is an excellent choice for management of such injuries.

Cleft Lip and Cleft Palate

What is a cleft lip and cleft palate?

During early pregnancy, separate areas or buds of your baby’s face develop individually and then join or fuse together. This failure of fusion results into a slit or separation of the face called a cleft. If the buds of the lip do not fuse together, it is called a cleft lip. If the buds of the palate (roof of the mouth) do not fuse together, it is called a cleft palate. If both the buds of the lip and palate do not fuse together, it is called a cleft lip and palate.

Cleft lip and cleft palate is basically a failure of fusion, but not a missing body part. They are among the most common birth defects affecting children in North America. The cleft can affect one or both sides of the face and can vary in severity.

Who will I see?

When treating cleft lip and palate, it is important to consider appearance, function, growth, speech, hearing, nutrition, and psychological development. A team of health care specialists (cleft team) will work together to evaluate and treat your child. The Oral and Maxillofacial Surgeon will play a key role to restore the appearance and function of children born with cleft lip and/or palate.

How is it repaired?

Repair of a cleft lip and/or palate requires multiple surgeries. The number of surgeries varies depending on the severity of the cleft. All of these surgeries are usually performed under general anesthesia (asleep and pain free).

A cleft lip is usually repaired by the time your baby is 3 to 6 months old. The surgery will improve your child’s facial appearance but also help for sucking and to form certain sounds made during speech.

A cleft palate repair occurs by the time your baby is 6 to 12 months old. The palate is usually repaired in 1 or 2 surgeries, depending on the severity of the cleft. This surgery will help your child’s speech and eating, by preventing air, food and liquids from going up into the nose.

A cleft in the gum may occur in association with a cleft lip. This may range from a small notch in the gum to a complete division of the gum into separate parts. The cleft of the gum is repaired with a bone graft, and is usually performed between 6 and 12 years old depending on your child’s dental development. This surgery is important for your child’s teeth and jaw growth.

The team of health care specialists might recommend other treatment or surgery to improve your child’s function and appearance. These may include, but are not limited to: speech therapy, orthodontic treatment (braces), corrective jaw surgery, ear tubes or hearing aids, lip and nose revision surgery, dental implant and restorations, etc

Jaw & Improper Bite

The Oral and Maxillofacial Surgeon is uniquely trained to correct patients with ‘bad bites’. In many cases, a bad bite can be corrected with orthodontic management, or with ‘braces’. Orthodontics and Dentofacial Orthopedics is another specialty of dentistry that is trained to correct bad bites with braces, or to work together with the Oral and Maxillofacial Surgeons to correct more severe cases that are often described as dentofacial deformities. Such deformities may include an excessive chin, or lack of chin, severe ‘buck teeth’ or excessively ‘gummy’ smiles. In all cases, the Orthodontist and Oral and Maxillofacial Surgeon will work as a team to diagnose the nature of the problems, and then co-ordinate a plan of treatment.

Surgical procedures can involve the upper and/or lower jaw and chin. The bones can be moved around in many directions so as to create a stable and functional bite, as well as improved facial appearance. These procedures are generally completed in the hospital environment under general anaesthesia so the patient is comfortable.  Some smaller procedures, such as those involving only the chin, can be completed as an out-patient in the surgeon’s office. While full recovery from many of these procedures may take a few weeks, the end result can be truly life changing, and most patients forget the recovery period once treatment is complete!

In most cases of dentofacial deformity there will be a requirement for orthodontic treatment prior to any surgical care. This period of preparation can last up to a year or more.  Once the surgical treatment has been provided, the braces will remain in place so that ‘fine tuning’ of the bite can be completed. In general, most combined surgical-orthodontic cases will take up to two years to complete.

Many Oral and Maxillofacial Surgeons and Orthodontists will use computer software to assist in the diagnosing and planning of dentofacial deformities. These software packages allow them to enter photographs and x-rays of patients, and then ‘virtually’ plan your surgery. In doing so, you may be able to obtain an idea of what your bite and appearance will look like once the journey is complete. Both the Oral and Maxillofacial Surgeon and Orthodontist receive extensive training and exposure to such cases, and are uniquely qualified to provide such advanced care.

References

The Web Page of The Canadian Association of Oral and Maxillofacial Surgeons (CAOMS)

https://caoms.com