You may well ask what a retired oral and maxillofacial surgeon with academic interests is doing writing an editorial for Your Witness. It is perhaps to explain what oral and maxillofacial surgery is and what an oral and maxillofacial surgeon does. It may also be helpful to identify some of the troublesome areas and to indicate how some of the problems may be avoided.
The principal aspects of the speciality to be considered are orofacial/ maxillofacial trauma, which includes craniofacial injuries as well as dentoalveolar (dental and jaw) trauma. Craniofacial deformities, both congenital and acquired, are relatively common, as are orthognathic (jaw deformity) surgery and cleft lip and palate correction and post-traumatic deformities. Head and neck surgery is very much a specialised area concerned with the management of tumours, vascular lesions and especially oral cancer – the latter often associated with smoking and excess alcohol consumption.
Oral surgery is an important sub-speciality, which deals primarily with pathology related to the teeth, infections around the jaws and face and pathology within the oral cavity, as well as salivary gland disease. Dentoalveolar surgery is an important part of the speciality concerned with the teeth and their supporting bone and it includes removal of teeth and implantology and the preparation of the jaws for prosthetic reconstruction.
The problem areas for the surgeon and those most likely to lead to litigation are dentoalveolar surgery, where there are pain problems, difficulties with surgical exodontia and failure of implants. In the field of trauma we see missed fractures, soft tissue damage and late diagnosis, and the occasional failure to achieve an optimal result.
The selection of cases for deformity correction may be difficult at times and with this elective surgery it is essential to achieve a good aesthetic result and normal dental function. Good pre-surgical planning and explanation of the risks are a prerequisite. The recognition of the dysmorphophobic patient with the aid of a psychologist is critical before any surgery is embarked upon to avoid an unsatisfiable patient.
In head and neck surgery the late recognition of tumours and oral cancer is a major problem, especially when they arise deep in the tissues of the head and neck. Often they are related to long-term smoking and alcohol consumption. True craniofacial surgery is a specialised area localised to only a few major centres. There is often a risk of mortality and it requires both neurosurgical expertise and appropriate consent.
Congenital deformity often leads to a patient-for-life and necessitates long-term planning and optimal timing of surgery.
The temporomandibular or jaw joint is a frequent cause of pain and discomfort and sometimes restriction of jaw movement and this is often associated with stress and psychological problems as well as trauma and arthritis. The highly innervated areas of the head and neck often make the diagnosis of facial pain difficult and lead to a misdiagnosis. In addition to local problems when working in a small speciality, care has to be taken to avoid missing general medical/surgical problems.
Many medico-legal problems arise in relation to informed consent, inadequacy of communication and risk assessment, and with elective surgery the choices of treatment and sometimes no treatment. The patient's concern will be for an aesthetic result and normal function, but any loss of sight, hearing, smell, taste and common sensation must be avoided in elective surgery, and as far as possible any multiplicity of surgical procedures to return the patient to normal masticatory function with normal speech.
Failure to warn the patient of the risk of nerve damage in dentoalveolar and orthognathic surgery is not an uncommon issue. Sometimes it is related to delegation to inexperienced staff or the failure to reexamine the surgical patient. Other problems that may arise are the failure to check the medical and drug history, leading to inappropriate antibiotic treatment and infection. There may be a lack of up-to-date knowledge and when this is accompanied by poor communication and poor management litigation may result.
One of the not uncommon issues that may arise is nerve damage due to crushing, traction, or cutting of the inferior alveolar or lingual nerves, leading to numbness of the lip and tongue as well as the surrounding structures. If there is only partial damage revisiting the nerve surgically is usually not helpful. If there is complete loss of sensation at three to six months then nerve repair may be worthwhile, but it never returns sensation to normality. Nerve damage in relation to trauma is not uncommon and must be identified prior to surgery, otherwise blame is likely to occur.
Scars around the face and neck tend to be visible; therefore there is a desire to try to approach various parts of the jaws and face through the oral cavity, or occasionally the nose, to avoid adding to the patient's discomfort and the likelihood of visible external scars and possibly damage to the facial nerve.
The face is a very visible area and residual deformity; nerve damage and scarring cannot easily be hidden as in other parts of the body. A thorough understanding of the anatomy of the area, as well as techniques to avoid an unaesthetic result, are essential for the oral and maxillofacial surgeon. Attention to detail, good communication and explanations and in general the avoidance of any persuasion of the patient to have surgery for a nonlethal condition are helpful for avoiding uncomfortable contacts with our legal colleagues.
The work of an oral and maxillofacial expert witness is essentially to summarise and explain the surgery carried out and to identify controversial aspects in the diagnosis and treatment of the patient who has a complaint or seeks damages from the perpetrator of trauma or the surgeon who has acted inappropriately. In addition it is to provide an unbiased opinion and explanation of what has occurred and the likely long-term outcome.