To What Extent is Each Area of Oral-Maxillofacial Surgery Practiced in the United States Today?

Abstract

In the United States, Oral and Maxillofacial Surgery (OMS) is a specialty of dentistry that focuses on the treatment of injuries, diseases, and defects of the head, neck, face, and jaws. There are approximately 1 hundred OMS residency programs and 4,100 practicing oral surgeons in the United States. Further, there are 29 fellowship programs that provide oral and maxillofacial surgeons additional training post- residency in craniofacial surgery, reconstructive surgery, oncologic surgery, and cosmetic surgery.1AAOMSEducation & Research.https://www.aaoms.org/education-researchDate accessed: December 20, 2021Google Scholar According to a survey conducted with chief residents at American OMS programs in 2013, approximately 55% of them planned on entering private practice, 29% planned on pursuing a combined private practice and academic career, 7% planned on completing a fellowship after residency, and 5% planned on entering a full-time academic career.2Aziz S.R. Ziccardi V.B. Chuang S.K. Training satisfaction versus dissatisfaction among chief residents in oral and maxillofacial surgery--a pilot survey.J Oral Maxillofac Surg. 2013; 71: 974-980Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Nevertheless, we are unaware of the distribution of actual fellowships pursued and how those training experiences inform the contemporary scope of practice among oral and maxillofacial surgeons in the United States. The purpose of the following brief study is to determine the extent to which each core area of OMS is practiced and the frequency that the corresponding procedures are performed in the United States. The following study received IRB approval from the institutional review board at Columbia University (Protocol number AAAT6105). The American College of Oral Maxillofacial Surgeons (ACOMS) was queried to identify members who were board-certified oral surgeons in the United States. Residents were excluded from the study. The member directory provided the respective email addresses, through which members were reached to partake in the study. Invitations were sent via email to complete an 11-question online survey in Qualtrics (Fig 1). The survey questions were categorized into 3 groups: 1- demographic information (Q1 to Q3) 2- training information (Q4 to Q6) 3- scope of practice (Q7 to Q11). The invitation was re-sent 4 more times in order to achieve a sufficient survey response rate. Participation in the study was completely voluntary, uncompensated, and anonymized. Completion of the survey indicated consent. Descriptive statistics (mean, frequency, range, standard deviations) were computed for all study variables when possible. After distributing the survey to 260 surgeons, we received 162 responses (survey participation rate, 62.3%). The mean age of our sample was 42.1 years, ranging from 29 to 76 years. The majority of the surgeons were male (79.5%) with single dental degrees (62.8%). The most common region of practice among respondents was the northeast (28.8%), while the least common was the west (21.2%). Post-residency fellowship training was pursued by 25 surgeons (16.0%). The most common fellowship pursued was cosmetic facial surgery (4.9%) and oral/head and neck oncologic surgery (4.9%). Regarding the areas of OMS, dentoalveolar surgery and dental implants (90.1%) were the most commonly performed. The least commonly practiced area was congenital craniofacial anomalies (14.8%) (Table 1).Table 1Demographic Characteristics, Degree Type, OMS Experience, and Fellowship Training of Our Study SampleTotal Number, n (%)Sample Size162 (100%)Age (yr), mean ± SD42.1 ± 10.4Sex Male124 (79.5%) Female32 (20.5%)Region of Practice Northeast45 (28.8%) Midwest35 (22.4%) South43 (27.6%) West33 (21.2%)Type of Degree Single Degree98 (62.8%) Dual Degree58 (37.2%)OMS Experience (yr), mean ± SD8.6 ± 9.6Fellowship Training Yes25 (16.0%) No131 (84.0%)Type of Fellowship Training Cosmetic Facial Surgery8 (4.9%) Oral/Head and Neck Oncologic Surgery8 (4.9%) P Pediatric Craniomaxillofacial Surgery (Cleft and Craniofacial Surgery)0 (0.0%) Microvascular Reconstructive Surgery4 (2.5%) Endoscopic Maxillofacial Surgery1 (0.6%)Areas of Oral and Maxillofacial Surgery Dentoalveolar surgery & Dental implants146 (90.1%) Maxillofacial Trauma115 (71.0%) Orthognathic Surgery95 (58.6%) Pathology & Reconstructive Surgery87 (53.7%) Aesthetic/Cosmetic Surgery26 (16.0%) Congenital Craniofacial Anomaly (ie, Cleft Palate)24 (14.8%) Open table in a new tab Regarding the area of pathology and reconstructive surgery, extirpative surgery (46.9%) was the most commonly performed procedure, while neck dissection (4.3%) was the least commonly performed procedure. Concerning aesthetic/cosmetic surgery, genioplasty (14.8%) was the most commonly performed procedure, while rhytidectomy (3.1%) was the least commonly performed procedure. Cleft lip and palate (13.6%) was the most commonly treated congenital anomaly, followed by Pierre-Robin sequence (8.0%). On the other hand, craniosynostosis (1.9%) was the least commonly treated congenital anomaly (Table 2).Table 2The Procedures Performed and Conditions Treated Within Each Area of OMS by Our Study SampleTotal Number, n (%)Pathology & Reconstructive Surgery Procedures Extirpative Surgery (ie, Resection)76 (46.9%) Neck Dissection7 (4.3%) Free Flap Surgery (ie, Microvascular Surgery)8 (4.9%) Pedicled (Local & Regional) Flap Procedures35 (21.6%)Aesthetic/Cosmetic Surgery Procedures Blepharoplasty19 (11.7%) Brow Lift10 (6.2%) Cheiloplasty8 (4.9%) Genioplasty24 (14.8%) Liposuction14 (8.6%) Otoplasty (ie, Pinnaplasty)15 (9.3%) Rhinoplasty (ie, Nose Job)17 (10.5%) Rhytidectomy (ie, Face Lift)5 (3.1%)Congenital Anomalies Cleft Lip & Palate22 (13.6%) Craniosynostosis (ie, Crouzon and Apert syndrome)3 (1.9%) Craniofacial Microsomia (ie, Hemifacial Microsomia)11 (6.8%) Treacher-Collins Syndrome12 (7.4%) Pierre-Robin Sequence13 (8.0%) Open table in a new tab The purpose of this brief study was to illustrate the range and scope of OMS in the United States today, specifically the core areas practiced and the corresponding procedures performed. Dentoalveolar surgery was the most commonly performed area of OMS, while congenital/craniofacial anomaly was the least commonly performed. The authors believe that most residents pursue a career in OMS due to an interest in dentoalveolar surgery, developed during the substantial exposure that they receive during dental school. The resident’s career interests notwithstanding, there is a much greater need for dentoalveolar surgery than, for example, congenital/craniofacial anomalies. According to the Agency for Healthcare Research and Quality, in 2009, 3% of approximately 548 million dental procedures were surgical. Dentoalveolar surgery is most prevalent among the geriatric population, as 11% of older adults had at least 1 surgical procedure in the year of 2009.3Manski R.J. Vargas C.M. Brown E. et al.Dental procedures among children age birth to 20, United States, 1999 and 2009.J Public Health Dent. 2015; 75: 10-16Crossref PubMed Scopus (9) Google Scholar Advanced caries, periodontitis, and other dental complications that warrant exodontia accompany the process of aging. Due to continual increases in life expectancy globally, the geriatric population, and hence the need for dentoalveolar surgery, will only increase in the future. Thus, we believe the predominance of dentoalveolar surgery within the context of OMS practice in the United States will continue in the years to come. The most common craniofacial deformity is cleft lip with cleft palate. Cleft lip with cleft palate has a frequency of 1 in 1,000 live births, with the remaining craniofacial anomalies being even less common.4Zins J.E. Gordon C.R. Handbook of Craniomaxillofacial Surgery. Singapore. World Scientific Publishing Co. Pte. Ltd, Hackensack, NJ2014Crossref Google Scholar Indeed, there are many more teeth that need to be extracted than there are craniofacial anomalies that need to be surgically corrected. It is also worth mentioning that craniofacial anomalies are managed by a diverse cleft-craniofacial team, including but not limited to pediatricians, orthodontists, auditory specialists, and speech therapists. The surgical component of care is performed by either a plastic surgeon, otolaryngologist, or oral and maxillofacial surgeon. By virtue of hospital politics, oral and maxillofacial surgeons often compete with plastic surgeons and otolaryngologists for positions in such cleft-craniofacial teams at hospitals, precluding them from performing these surgeries when not included. Concerning the area of pathology and reconstructive surgery, extirpative surgery was the most commonly performed procedure among the oral and maxillofacial surgeons surveyed, while neck dissections were the least common. Pathology and reconstructive surgery is a rather novel area in the context of OMS in the United States. It was not until the 1990s that oncologic surgery fellowship programs were established and over time, were refined by the AAOMS Committee on Residency Education. Today, there are 7 CODA-approved oncology fellowship programs in the United States for oral and maxillofacial surgeons. These fellowships have trained many OMS residency graduates since their inception who, in turn, went on to serve as faculty members in OMS academic programs. While fellowship programs train fellows in the full scope of oncology surgery to a competent level, a survey sent to all 64 fellowship-trained oral and maxillofacial surgeons in the United States determined that nearly half of them do not perform microvascular surgery.5Kademani D. Woo B. Ward B. et al.Oral/head and neck oncologic and reconstructive surgery fellowship training programs: Transformation of the specialty from 2005 to 2015: Report from the AAOMS Committee on maxillofacial Oncology and reconstructive surgery.J Oral Maxillofac Surg. 2016; 74: 2123-2127Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar This explains the infrequency of flap surgery and neck dissections in our study. Regarding aesthetic/cosmetic surgery procedures, genioplasty was the most common, and rhytidectomy was the least common. The Commission on Dental Accreditation (CODA) deems facial cosmetic and reconstruction a major category, for which it mandates a minimum requirement of procedures necessary for graduation. Hence, the scope of OMS training programs must incorporate at least 20 facial cosmetic and/or facial reconstructive procedures to meet this requirement. Nevertheless, it has been speculated that OMS residents do not gain enough experience with cosmetic procedures to be able to perform them competently without additional post-residency fellowship training. Diepenbrock et al. distributed surveys to all CODA-accredited OMS programs to determine the total number of aesthetic/cosmetic procedures completed per graduating resident. The authors determined that genioplasty and rhinoplasty comprised nearly half of all such procedures, with rhytidectomy comprising merely 8% of the procedures. Indeed, manipulating the chin as it relates to the upper and lower jaws often helps to achieve facial balance. As such, genioplasties are not uncommonly completed concurrently with routine orthognathic surgery. Concerning congenital anomalies, procedures of the cleft lip and palate were the most common, while syndromic craniosynostosis (ie, Crouzon and Apert syndrome) was the least common. The authors believe the relatively greater incidence and prevalence of cleft lip and palate compared to syndromic craniosynostosis underlies this finding. Syndromic craniosynostoses are the co-occurrence of prematurely fused sutures alongside other anomalies in a consistent pattern. These include Crouzon’s syndrome and Apert’s syndrome, which have a frequency of 1 in 25,000 births and 1 in 160,000 births, respectively. The surgical procedures used to correct the skeletal deformities, such as the monobloc osteotomy with distraction osteogenesis, are more challenging and specialized than those for cleft lip and palate, which can further explain the rarity of syndromic craniosynostoses among OMS patients.4Zins J.E. Gordon C.R. Handbook of Craniomaxillofacial Surgery. Singapore. World Scientific Publishing Co. Pte. Ltd, Hackensack, NJ2014Crossref Google Scholar REPLY: TO WHAT EXTENT IS EACH AREA OF ORAL-MAXILLOFACIAL SURGERY PRACTICED IN THE UNITED STATES TODAY?Journal of Oral and Maxillofacial SurgeryVol. 81Issue 1PreviewWe thank Guo et al for their interest in our article titled ‘To What Extent is Each Area of Oral-Maxillofacial Surgery Practiced in the US Today?’1 The authors did a great job elucidating the results of our study, providing answers to why things are the way they are today in the field of oral and maxillofacial surgery (OMS) within the United States. Specifically, Guo et al highlight several financial, economic, political, and bureaucratic factors that are constricting the practice of OMS to predominantly dentoalveolar surgery. Full-Text PDF RE: To What Extent Is Each Area of Oral-Maxillofacial Surgery Practiced in the US Today?Journal of Oral and Maxillofacial SurgeryVol. 81Issue 1PreviewWe read with great interest the article “To What Extent Is Each Area of Oral-Maxillofacial Surgery Practiced in the US Today?” by Stanbouly et al.1 The authors provided valuable information on the scope of practice and frequency of corresponding procedures performed by oral and maxillofacial surgeons in the United States. We believe it would be thought-provoking to explore the rationale behind the decisions to pursue mainly dentoalveolar surgery and dental implants by these surgeons. Full-Text PDF RE: “To What Extent Is Each Area Of Oral-Maxillofacial Surgery Practiced In The US Today?”Journal of Oral and Maxillofacial SurgeryVol. 80Issue 7PreviewDear Editor:—Mr Stanbouly’s article, “To What Extent Is Each Area of Oral-Maxillofacial Surgery Practiced in the US Today?” is thought-provoking. The exceptional training of the oral and maxillofacial surgeon can make the fellowship-trained oral and maxillofacial surgeon a star in head and neck oncologic and reconstructive surgery, cleft and craniofacial surgery, or facial and cosmetic surgery. Although small in numbers, these uniquely trained surgeons give an even greater level of oral and maxillofacial surgery (OMS) relevance in the healthcare arena as they advance the mission of providing patient access to safe and effective care. Full-Text PDF