Oral Health Group

Evolving Scope of Practice

June 1, 2011
by Bruce R. Pynn, MSc, DDS, FRCD(C), FICD

Since the Second World War, the scope and complexity of Oral and Maxillofacial Surgery in North America has steadily progressed beyond the practice of exodontia. Significant advances were made in the medical and surgical management of victims of trauma, temporomandibular disorders, and treatment of dentofacial deformities, infections and oral pathology, as well as reconstructive procedures for oncology patients.

In the early 1950s, the mandible was the primary site for the surgical correction of dental facial deformities as maxillary surgery was limited and often avoided due to the potential for severe bleeding or compromising the blood supply (ischemic necrosis) and the resultant loss of maxillary segments or in some cases the entire maxilla.


However, ongoing basic research by William Bell and others ultimately provided the reassurance that ischemic necrosis of the maxilla and/or maxillary segments could be avoided by maintaining well-vascularized soft tissue attachments to the upper jaw.

In 1966, in Washington DC, in a landmark presentation by Professor Hugo Obwegeser of Zurich, the sagittal split ramus osteotomy (SSRO) and other surgical procedures were introduced to North American Oral Surgeons. This was a turning point for oral and maxillofacial surgery in North America. This SSRO technique rapidly became the most popular and versatile procedure for the correction of a number of mandibular deformities and in concert with maxillary surgery, comprises a surgical combination that was capable of correcting a variety of dentofacial deformities.

Consequently, North American oral and maxillofacial surgeons were now able to correct skeletofacial deformities by operating on the jaw in which the dysplasia existed, (e.g. a retruded maxilla could be readily advanced without compromising the surgical result by mandibular setback). It became clear that almost any dentofacial deformity was amenable to surgical correction. Then in the early 1980s as rigid fixation techniques developed and were applied to orthognathic surgery, patients were able to function during healing.

A similar evolution has been occurring in the area of tempormandibular joint (TMJ) surgery. In 1957, Dr. Fred Henny developed and described the TMJ high condylectomy an operation that was rapidly adopted as a favoured procedure in North America for the treatment of TMJ pain dysfunction that displayed x-ray signs of osteoarthritis. At approximately the same time in the United Kingdom (UK), the closed condylotomy procedure developed by Sir Terence Ward became the most popular operation in the U.K. for the treatment of TMJ pain dysfunction when there were no radiographic signs of TMJ osteoarthritis.

In 1975, Dr. Masatoshi Ohnishi reported his experience with operative arthroscopy of the TMJ in the Japanese Journal of Stomatology. This technique was subsequently endorsed by a number of oral and maxillofacial surgeons as a safe and effective surgical procedure for the treatment of TMJ internal derangement that failed to improve with a reasonable course of appropriate non-surgical therapy.

In the latter part of the 1970s, TMJ disc repositioning surgery was described by Farrar and McCarty, Wilkes, Dolwick and others and rapidly became a broadly utilized surgical procedure for the correction of TMJ internal derangement that was refractory to appropriate non-surgical therapy.

More recently, the introduction of TMJ arthrocentesis, a minimally invasive procedure, has reportedly proven to be almost as effective as TMJ arthroscopic surgery in reducing TMJ pain and increasing TMJ mobility. Currently, TMJ arthrocentesis appears to be the surgical option of choice for the treatment of refractory TMJ pain dysfunction.

In the past two decades the subjects of osseointegrated implants and bone grafting, cosmetic surgery, distraction osteogenesis and endoscopic techniques, have all played a dominant role at scientific meetings and workshops and in the oral and maxillofacial surgery literature. The adoption by our specialty of surgical procedures that have not been part of our traditional domain e.g. cosmetic surgery, oncologic, and ablative-reconstructive surgery, places an onerous responsibility on our teaching programs to ensure that the education and training of all residents in these expanded scope procedures is at least equivalent to that obtained by residents in competing specialties.

The steady expansion of the scope of oral and maxillofacial surgery provides the surgeon with the opportunity to utilize his/her knowledge and skills in order to achieve an optimal functional and esthetic result for the patient.OH

Bruce R. Pynn, DDS, MSc, FRCDC , oral and maxillofacial surgery, Thunder Bay, ON. He is the oral and maxillofacial surgery board member for Oral Health. Thanks to Dr. Simon Weinberg for his wisdom and knowledge in crafting this editorial.

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