The specialty of oral and maxillofacial surgery (OMFS) in Europe – Part 2: training environment including the new Union of European Medical Specialists (UEMS) Oral and Maxillofacial Surgery European Training Requirement (OMFS ETR)

OMFS training in Europe has incrementally improved over the last 50 years. However, not all European nations have a formal written curriculum/syllabus, quality indicators, exit examinations, or guidelines for training programmes or trainers. In 2021 the OMFS Section of the Union of European Medical Specialists (UEMS) created an OMFS European Training Requirement (OMFS ETR) to help address these gaps and raise training standards in Europe. This paper includes key lessons from OMFS training programmes across Europe. It also summarises the new OMFS ETR as a comprehensive curriculum and syllabus. The ETR is a resource for nations with dual degree or single medical degree versions of the specialty. More importantly, it can act as a template for the handful of European Economic Area (EEA) nations that do not currently have a recognised OMFS specialty in Directive 2005/36 EU or the European Free Trade Association Treaty. By outlining the breadth and depth of the specialty, the ETR will be useful for competent regulatory authorities as well as OMFS trainees and trainers, patients, and politicians. The OMFS ETR includes key competencies and capabilities alongside training structures and documentation. A free unrestricted Access© database can be downloaded from www.omfsuesm.eu so OMFS experience can be recorded in a similar way across international borders. The OMFS ETR will be a living document. As it is unlikely that OMFS will remain frozen in time, this training document will also evolve. Its true value will become clear as it is used by current and future OMFS surgeons.     

The future of oral and maxillofacial surgery – retired viewpoint

A reasoned argument as to why the status quo for oral and maxillofacial surgery training is not sustainable and an alternative is suggested. It is argued that the current financial burden, future pension provision and unacceptable work/life balance must be addressed immediately to ensure uptake of training posts for preservation of the specialty.     

Lost tribe? Awareness of oral and maxillofacial surgery (OMFS) among the general public

OMFS has important links with other disciplines in medicine and dentistry. Therefore it is important that people are aware of this speciality. A study was devised to determine the awareness of OMFS among the general public and to improve their understanding. A questionnaire was distributed among the participants attending a dental practice. 100 participated and the mean age was 42.5 years. Only 17% were aware of OMFS. 96% recognised the duty of OMFS practitioner while 74% did agree dual qualification was necessary. 68% identified hospital as the main place of work and 61% thought that the training was 5–6 years long.     

Prevalence and incidence of oromandibular dystonia: an oral and maxillofacial surgery service–based study

Objectives

Oromandibular dystonia is a focal dystonia characterized by sustained or intermittent contractions of the masticatory and/or tongue muscles. This epidemiological study aimed to estimate the prevalence and incidence of oromandibular dystonia in Kyoto (population: 1,465,701).

Materials and methods

The population sample was citizens of Kyoto who visited our department between 2015 and 2019 and were differentially diagnosed by an oromandibular dystonia specialist having idiopathic (primary) and acquired (secondary) oromandibular dystonia. A total of 144 patients (100 women and 44 men; mean age, 57.5 years) were analyzed for clinical features, and the prevalence (prevalence date, January 1, 2020) and annual incidence were estimated.

Results

The male-to-female ratio was 1:2.3 (p<0.001). Age at onset was significantly (p<0.01) earlier in men (47.5 years) than that in women (56.9 years). The crude prevalence of oromandibular dystonia was estimated at 9.8 per 100,000 persons (95% confidence interval: 8.3–11.6) (idiopathic dystonia, 5.7 [4.6–7.1]; tardive dystonia, 3.4 [2.5–4.5]) and incidence at 2.0 (1.3–2.8) per 100,000 person-years (idiopathic dystonia, 1.2 [0.68–1.9], tardive dystonia, 0.68 [0.32–1.3]). The prevalence was 13.0 (10.5–15.8) in women and 6.3 (4.6–8.5) in men. All age groups showed female predominance. The highest prevalence was 23.6 (14.4–36.5) in women aged 60–69 years.

Conclusions

As this is an oral and maxillofacial surgery service–based study, the actual prevalence of oromandibular dystonia may be even higher.

Clinical relevance

It was suggested that oromandibular dystonia might be more common than cervical dystonia or blepharospasm.

     

Microsurgical reconstruction of the head and neck – Current concepts of maxillofacial surgery in Europe

IntroductionMicrovascular surgery following tumour resection has become an important field of oral maxillofacial surgery (OMFS). This paper aims to evaluate current microsurgical practice in Europe.MethodsThe questionnaire of the DOESAK collaborative group for Microsurgical Reconstruction was translated into English, transformed into an online based survey and distributed to 200 OMFS units with the aid of the European Association for Cranio-Maxillo-Facial Surgery (EACMFS).Results65 complete and 72 incomplete questionnaires were returned. Hospitals from the United Kingdom, France, Italy, the Netherlands, Spain, Belgium, Greece, Slovenia and Lithuania participated. 71% of contributing centres were university hospitals, 87% out of these perform microvascular tumour surgery at least on a two-weekly base. Overall complication rate was at around five percent. Most frequently used transplants were the radial forearm flap and the fibular flap. The perioperative management varied widely. Success factors for flap survival, however, were uniformly rated, with the surgical skill being the most important factor, followed by the quality of postoperative management. Medication seems to play a less important role.ConclusionWithin Europe microvascular surgery is a common and safe procedure for maxillofacial reconstructive surgery in the field of OMFS. While there is a major accordance for the surgical procedure itself and the most frequently used flaps, perioperative management shows a wide variety of protocols with low presumed impact on surgical outcome.     

Microvascular reconstructions in oral and maxillofacial surgery — Results of a survey among oral and maxillofacial surgeons in Germany,Austria, and Switzerland

This study aimed to evaluate the use of microvascular free flaps (MFF) in oral and maxillofacial surgery (OMFS) in Germany, Austria, and Switzerland.A dynamic online questionnaire, using 42–46 questions, was sent to OMF surgeons based in hospitals in Germany, Austria, and Switzerland. The questionnaire was evaluated internally and externally. Aside from general information, data were collected on organizational aspects, approaches, MFF types and frequency, presurgical planning, intraoperative procedures, perioperative medications, flap monitoring, and patient management.Participants mostly performed 30–40 MFF each year (11/53). Most stated that the COVID-19 pandemic did influence MFF frequency (25/53) to varying extents. Radial forearm flap was most frequently used (37/53), followed by ALT (5/53), and fibula flap (5/53). Primary reconstruction was performed by most participants (35/48). Irradiated bony transplants were mostly used for implant placement after 12 months (23/48). Most participants (38/48) used reconstruction plates, followed by miniplates (36/48), PSI reconstruction (31/48), and PSI miniplates (10/48). Regarding the postoperative use of anticoagulants, low-molecular-weight (37/48) and unfractioned heparins (15/48) were widely used, most often for 3–7 days (26/48). Clinical evaluation was mostly preferred for flap monitoring (47/48), usually every 2 h (34/48), for at least 48 h (19/48).Strong heterogeneity in MFF reconstructions in OMFS was found, especially regarding the timepoints of reconstruction, types of osteosynthesis, and postoperative MFF management. These findings provide the chance to further compare the different treatment algorithms regarding relevant MFF aspects, such as postoperative management. This could create evidence-based treatment algorithms that will further improve the clinical outcomes in MFF reconstructions.     

Changes in United Kingdom oral and maxillofacial surgical specialty trainees since 1995 – numbers,gender, first degrees,and nations of origin

Training in UK surgery has changed dramatically since 1995, from a relative lack of structure to time-limited and highly documented programmes. Training in oral and maxillofacial surgery (OMFS) has shared these changes and included some significant changes of its own. Minutes from the OMFS Specialty Advisory Committee (SAC) were reviewed over the last 25 years to record the number and location of newly approved posts. The General Medicine Council’s (GMC) OMFS specialist list in 2019 was combined with the records of OMFS specialists’ dental qualifications held by the General Dental Council (GDC) and augmented from a database of OMFS trainees and consultants in the UK. Data on demographics, location, and nature of the first medical or dental degree were noted for analysis.A total of 691 OMFS specialists and trainees were identified from GMC, OMFS SAC and consultant databases. Of these, 12 consultants held only dental qualification/registration. First degree data could not be obtained for 12 specialists (all male). A further 20 OMFS specialists, whose training was outside the UK, were also excluded from further analysis.In 1995 there were 95 national training posts, by 2013 there were 150. Over the last quarter of a century, there has been an increase in medicine first trainees, an increase in female trainees and specialists, and a relative decrease in OMFS trainees from the Indian subcontinent. The varied origins of the OMFS workforce has contributed to greater diversity and inclusion within the specialty. In the UK, OMFS appears to have produced the correct number of specialists whilst maintaining a high standard of training. The next change in OMFS training programmes is to deliver The Postgraduate Medical Education and Training Board’s (PMETB) recommendations. As we move to achieve this it is imperative that as new doors open, we do not close others.     

United Kingdom immigration and emigration of oral and maxillofacial Surgery (OMFS) specialists 2000-2020: how might Brexit impact on OMFS?

The United Kingdom left the European Union (EU) in January 2020. As it is unclear how many of the rights of OMFS surgeons to travel and work will remain after the transition period, we have reviewed how these rights have been used in the past. The OMFS specialist list from the GMC was compared with a database of current OMFS colleagues. Data were analysed using WinStat® (R. Fitch Software). Of 494 active surgeons on the OMFS specialist list, 23 (5%) completed their OMFS training outside the UK. Of these, 22 were specialists from Europe of whom 12 were substantive NHS consultants with others working as Fellows or visiting the UK occasionally. Two per cent of UK OMFS consultants are -specialists from Europe, the majority from Greece. Of the OMFS specialists who completed training in the UK since 1995, 24 are currently working outside the UK, and of them, 16 left the UK to return to their nation of origin (all 11 of those working in the European Economic Area [EEA] were born there). Of the seven UK-born specialists working overseas, none was working in the EEA. Twenty per cent of UK trainees whose primary degree was known (n = 117) received their primary qualification outside the UK, 38 in from the EU, and 79 from further afield. The majority of these UK trained specialists with non-UK first degrees (n = 101) stayed in the UK to work after training. The most significant impact of Brexit on OMFS could be a restriction on the opportunity for non-UK doctors and dentists to come to the UK to train and stay to work.     

Management of oral and maxillofacial infections in a regional unit: a seven day service?

The provision of a seven-day National Health Service (NHS) has been proposed as a means to halt the weekend delay in treatment that has been described in some studies. We tested the emergency services in the Oral and Maxillofacial Surgery Department at Northampton General Hospital to find out whether they provided a seven-day service. Data were collected prospectively and retrospectively for all patients admitted to the Oral and Maxillofacial Department at Northampton General Hospital with infections of the head and neck during a period of 29 months (January 2014–May 2016). Duration of hospital stay and waiting time for operation were compared for weekday and weekend admissions to find out if there were changes in either outcomes or waiting times. The severity of infection between the two periods was also assessed using the serum C reactive protein (CRP) concentration as a marker. A total of 293 patients were admitted with head and neck infections, and the mean (range) duration of stay for those admitted on weekdays was 3 (1–14) days and for patients admitted at a weekend was 3 (1–17) days (p = 0.14). However, the waiting times for operation were significantly longer during the week (mean (range) 0.6 (0–8) days) than at the weekend (0.5 (0–3) days, p = 0.04). We know of no other published studies about provision of a seven-day service in oral and maxillofacial surgery. Our results show that we are already working to that standard, and this raises the question of whether any changes are required to current practice in the NHS, with their associated costs and upheaval.     

Submental intubation in oral and maxillofacial surgery: a systematic review 1986–2018

Submental intubation is a low-risk alternative to tracheostomy when nasotracheal or orotracheal intubation is not appropriate. To improve the selection of patients and clinical outcomes we have explored published papers on submental intubation in oral and maxillofacial surgery, and included a proposal for a decision pathway. Systematic searches of PubMed, Scopus, and Cochrane databases for papers published between 1986 and 2018 yielded 116 eligible articles (one randomised controlled trial, 61 case series, 40 case reports, six surgical techniques, and eight letters) that included 2 229 patients. Measured outcomes were the indications, techniques, devices used, time taken to complete the procedure, and complications. Indications were trauma (81%), orthognathic surgery (15%), disease (2%), and cosmetic surgery (1%). Technical preferences were for a one-tube (84%) over a two-tube technique (6%), and a paramedian (52%) over a median incision (33%). The preferred device was a reinforced endotracheal tube (85%). The mean (range) intubation time was 10 (2–37) minutes. The complication rate was 7% (n = 152), the most common being superficial skin infection (n = 54), hypertrophic scarring (n = 18), and damage to the tube apparatus (n = 15). Submental intubation has minimal complications, takes a short time to do, and it is a useful alternative to tracheostomy in some oral and maxillofacial operations. More robust evidence regarding the selection of patients, modifications to the technique, and a comparison of risk with that of tracheostomy, are needed for further evaluation of its feasibility.     

Dental foundation year 2 training in oral and maxillofacial surgery units – the trainees’ perspective

Most dental foundation year 2 (DF2) training takes place in oral and maxillofacial surgery (OMFS) units. We did a survey of DF2 trainees in these units by telephone interviews and an online questionnaire to find out about their experience of training and their career aspirations. A total of 123 responded, which is roughly 41% of the total estimated number of trainees. Trainees applied for these posts mainly to improve their dentoalveolar skills (50%), and this was cited as the best aspect of the training. Most (81%) were on-call at night and this was generally thought to be a valuable training experience (77%), but 20% thought that it was the worst aspect of the job. Most did not regret taking up the post although the experience had caused 75% to alter their intentions about their future career; general dental practice was the commonest choice. In conclusion, trainees are generally satisfied with their training and these positions have guided their choices about future careers.     

The indication and application of computer-assisted navigation in oral and maxillofacial surgery—Shanghai's experience based on 104 cases

ObjectiveTo explore the indication and application of computer-assisted navigation in oral and maxillofacial surgery.Patients and methodsOne hundred and four patients including 34 zygomatic-orbital-maxillary fractures, 27 unilateral TMJ ankylosis, 29 craniofacial fibrous dysplasia, 9 mandibular angle hypertrophia, 3 cartilage/bone tumours of jaw and 2 cases with facial foreign bodies were enrolled in this study.CT scans were performed and data was saved in DICOM (digital imaging and communications in medicine) format. The osteotomy lines, amount and range of resection, the reduction position of bony segments and the reconstruction morphology was determined and displayed by preoperative simulation with mirroring and superimposing procedures. All operations were performed under the guidance of navigation system. The accuracy of navigation was evaluated by comparing the postoperative CT 3-D model with preoperative surgical planning.ResultsThrough registration, an accurate match between the intraoperative anatomy and the CT images was achieved. The systematic error checked by computer was within 1 mm. All operations were performed successfully with the guidance of real-time navigation. The mean error between virtual simulation and surgical results was 1.46 ± 0.24 mm. All patients healed uneventfully and function and profile was improved significantly.ConclusionsWith the opportunity to perform preoperative planning, surgical simulation and postoperative prediction, computer-assisted navigation shows great value in improving the accuracy of maxillofacial surgery, reducing operation risk and postsurgical morbidity, and restoring facial symmetry. It is regarded as a valuable technique in these potentially complicated procedures.     

The "dual degree". Does it change the scope of practice for oral and maxillofacial surgery?

The scope of practice for OMS is not, nor should it ever be, an issue of single or dual degree but must be related to the surgeon being trained to competence in the procedures performed. Future evolution will be based on continual advancements in the specialty and related areas as well as the development of new techniques. While the medical education may improve a core fund of general knowledge, the surgical residency and/or fellowship is the determinant of surgical competence and scope of practice.     

The temporomandibular joint of California sea lions (Zalophus californianus): Part 1 – Characterisation in health and disease

Objectives

This study aimed to characterise the histologic, biomechanical and biochemical properties of the temporomandibular joint (TMJ) of California sea lions. In addition, we sought to identify structure–function relationships and to characterise TMJ lesions found in this species.

Design

Temporomandibular joints from fresh cadaver heads (n = 14) of California sea lions acquired from strandings were examined macroscopically and microscopically. The specimens were also evaluated for their mechanical and biochemical properties. Furthermore, if TMJ arthritic changes were present, joint characteristics were described and compared to healthy joints.

Results

Five male and 9 female specimens demonstrated macroscopically normal fibrocartilaginous articular surfaces and fibrous discs in the TMJ. Out of the 9 female specimens, 4 specimens had TMJ lesions were seen either in the articular surface or the disc. Histologically, these pathologic specimens demonstrated subchondral bone defects, cartilage irregularities and inflammatory cell infiltrates. The normal TMJ discs did not exhibit significant direction dependence in tensile stiffness or strength in the rostrocaudal direction compared with the mediolateral direction among normal discs or discs from affected joints. The TMJ discs were not found to be anisotropic in tensile properties. This feature was further supported by randomly oriented collagen fibres as seen by electron microscopy. Furthermore, no significant differences were detected in biochemical composition of the discs dependent upon population.

Conclusion

The TMJ and its disc of the California sea lion exhibit similarities but also differences compared to other mammals with regards to structure–function relationships. A fibrous TMJ disc rich in collagen with minimal glycosaminoglycan content was characterised, and random fibre organisation was associated with isotropic mechanical properties in the central region of the disc.