Chapter 1
Introduction

Learning Outcomes

At the end of this chapter you should have an understanding of:

1. 1. Where maxillofacial surgery is carried out and by whom.
2. 2. The procedures that are included under the umbrella of maxillofacial surgery.
3. 3. Why maxillofacial surgery is undertaken.
4. 4. The members of the dental team that make up the maxillofacial team.
5. 5. The referral system.
6. 6. The legal aspects associated with the provision of maxillofacial procedures.

Introduction

Maxillofacial surgery forms an appreciable part of daily practice for the non-specialist dentist. Some restrict their practice to straightforward extractions while others undertake a wide range of surgical procedures associated with the jaws, teeth and soft tissues. Many refer to this practice as minor oral surgery. There are specialist centres and departments within local dental and general hospitals where clinicians are committed to procedures that come under the umbrella of maxillofacial surgery. These include:

• Straightforward extractions.
• Surgical removal of impacted and broken-down teeth.
• Surgical removal of retained roots.
• Biopsies, which involve a sample of tissue being removed and sent for diagnosis to confirm or eliminate a diagnosis.
• Exposure of impacted canines for patients undergoing orthodontic treatment.
• Frenectomy, which is where either the labial or lingual frenulum is released.
• The removal of cysts.
• Alveolectomies, undertaken prior to dentures being supplied to a patient. This involves the smoothing off of the alveolar ridge.
• Performing apicectomies where other root treatments have failed or it is impossible for them to be carried out. In dentistry an apicectomy comes under the auspices of endodontic treatments; however, as they involve raising a flap, it is classed as a surgical procedure.
• Removal of tumours.
• Reconstruction of the face following trauma or removal of facial tissues and structures.
• Cosmetic treatments such as a face lift, rhinoplasty (the correction and reconstruction of the nose) or otoplasty (ears that stick out), commonly known as bat ears.
• Orthognathic surgery, which is where surgical intervention is undertaken to correct jaw discrepancies.

For a clinician to undertake the last four procedures he/she must be dually qualified in dentistry and medicine.

The reason these procedures may be undertaken can be attributed to disease, accidental injury, congenital malformation, periodontal problems and caries. These treatments can be carried out with the use of local anaesthetic, either on its own or in combination with a form of conscious sedation, or a general anaesthetic, thereby involving many team members.

The maxillofacial team comprises the following members:

• Consultant.
• Registrar.
• Oral surgeons.
• Senior house officers.
• Dental nurses.
• Anaesthetists.
• Recovery nurses who are state registered, with anaesthetic training.

When patients are being treated for cancerous lesions, a multi-disciplinary team approach involves additional team members. These are:

• Oncologists (a specialist who treats cancerous lesions).
• Radiologists (a specialist in interpreting images of the body).
• Microbiologists and pathologists (who study micro-organisms and how they affect the human body).
• Specialist head and neck nurses (registered general nurses).
• Macmillan nurses (registered general nurses who specialise in the care of oncology patients).
• Speech and language therapists (specialists who are trained to aid patients with their speech).
• Dieticians (a specialist in nutrition or dietetics).

Patient Referral

Patients are referred to specialist units and departments within local dental and general hospitals where maxillofacial surgery is undertaken. Reasons for referring patients can include the following:

• It is thought that the patient will be managed more appropriately due to the complexity of the treatment required, or their medical history.
• The patient's general dental practitioner requires a specialist opinion.
• The patient's general dental practitioner does not offer the treatment the patient requires.
• The general dental practitioner offers the treatment the patient requires, but does not offer the method of pain and anxiety control the patient requests.

When a general dental practitioner refers a patient for maxillofacial treatment they must provide a referral letter which will, as a minimum, contain the following information:

• Patient personal details: name, address, telephone number and date of birth.
• Patient medical history.
• The presenting dental problem.
• The reason for the referral.
• The name and contact details of the referring general dental practitioner.
• Any radiographs taken.

Many specialist units and departments within local dental and general hospitals have forms that can be completed to make the referral process easier. If the general dental practitioner or the patient's general practitioner suspects a cancerous lesion, they can use a fast track referral form. Some forms request additional information to that listed above in order to allow the member of the maxillofacial surgery team assessing the referral form/letter to assign a suitable time frame for the patient to be seen. Once this has been undertaken, an appointment will be sent to the patient for a consultation. Once the patient has been seen by the specialist unit or departments within local dental and general hospitals, an outcome letter is sent to the referring practitioner. This will contain a diagnosis and whether the patient has been or will be treated by a member of the maxillofacial team, or are being returned into the care of a general dental practitioner or general practitioner for ongoing treatment and care. Any dental radiographs furbished by the general dental practitioner will be returned.

Legal Aspects Associated with Maxillofacial Surgery

The legal aspects associated with maxillofacial surgery are no different from any other specialist field within medicine and dentistry. On a daily basis, the maxillofacial surgeon must consider the following legal and ethical issues:

• Negligence.
• Confidentiality.
• Consent.
• Accusations of assault.

Negligence

For a member of the maxillofacial team to be negligent, they will have acted outside the law and/or will have undertaken treatment that is not satisfactory. All members of the maxillofacial team have a duty of care to ensure that every patient is treated safely, with a high standard of care being provided. Good communication with patients and the rest of the maxillofacial team is therefore paramount to avoid any misunderstandings. The taking of consent is mandatory, as this will provide documentation of which treatments were agreed and those that were not. Well-kept dental notes will provide a history of the patient's past, present and future treatment. All members of the maxillofacial team must be trained for their area of responsibility and must not work outside that remit and scope of practice. A safe clinical environment should be provided for all, with any equipment being serviced at recommended intervals to avoid any accidents or incidents.

Confidentiality

When a patient provides the maxillofacial team with any information about themselves, they expect it to be kept confidential. This means that all members of the maxillofacial team must not divulge any information relating to patients. They must also ensure that all precautions are taken to prevent any information being divulged unintentionally. All patient information must be kept secure as patients discuss delicate issues with the maxillofacial team/clinician pertinent to their treatment. Patient information cannot be released without the consent of the patient. However, there are exceptional situations where patient information can be disclosed without requesting the patient's consent. These include:

• Where it would benefit them (e.g. their health was at risk).
• Where it was considered that a serious crime was imminent.
• In the interests of the general public.

If any of these situations occur the patient's consent should ideally still be sought and, if not given, only minimal information should be released. Patients should always be aware that their information...