Oral and Maxillofacial Surgery: Conditions We Treat
Offering expert diagnosis and treatment of disorders of the mouth and facial area, oral and maxillofacial surgeons at BMC perform extractions to dental implants, from corrections of dental deformities to the most complex facial reconstruction, and from TMJ disorders to cancer.
Normally in the early weeks of child development, the right and left sides of the upper lip and the roof of the mouth grow together and fuse. Occasionally, one or all of these structures fail to fuse resulting in a cleft lip and/or palate; a phenomenon which can be partial or complete. Over many years, surgeons and other healthcare providers have developed multidisciplinary teams to deal with cleft lip and palate in addition to other associated problems that can occur. This team approach is critical in the care of these children as there are nutritional issues, social issues, speech and language development concerns, as well as surgical issues that need to be addressed.
Surgeons at BMC are trained to be involved in all aspects of a child's surgical care, depending on their needs. Those born with a cleft lip and/or palate can find individualized treatment and a team approach with surgeons practicing at BMC who are willing to see your child at any point during the process from birth to any necessary revisions in adulthood.
Providers will spend the necessary time to answer questions throughout the process, educate and support the entire family, and foster an environment where children can grow with a sense of self-respect and self-esteem that goes well beyond the physical defect.
Cranio-maxillofacial trauma encompasses any injury to the soft tissues of the face, neck, and scalp, as well as to the hard tissues of the facial skeleton including the teeth, facial bones, or the cranium. They also range in severity depending on the cause of the injury and can often involve injuries to other parts of the body.
Facial trauma can be caused by any number of things including motor vehicle accidents, sports injuries, interpersonal violence, falls, work-related accidents, and many other causes. Since the face is perhaps the most prominent feature of our physical identity, having a qualified provider treat your facial injury is critical. Surgeons at BMC are uniquely trained and capable of managing all facets of these injuries by receiving extensive experience throughout their careers in both the dental and medical aspects of soft and hard tissue trauma of the face.
Soft tissue injuries can be some of the most devastating injuries affecting any structure on the face and prove to be the most complex wounds to manage. These injuries can involve the soft tissues of the oral cavity, but with the department's dental background, BMC providers have a unique understanding of the relationship between the oral hard and soft tissues and can repair the soft tissues, allowing for optimal aesthetics and function. Soft tissue injury to the external structures of the face and neck are of obvious concern and BMC surgeons are capable of providing the best possible cosmetic and functional result. The providers in our practice are also capable of dealing with injuries that involve specialized structures such as facial nerves, sensory nerves of the face and mouth, and the ducts that drain tears and saliva.
Injuries to the hard tissues of the face range in severity and location depending on the location of the injury. The surgeons in our practice are well versed in management of injuries to all bones of the facial skeleton and cranium along this range of severity. BMC's approach is unique because of its dental and surgical background with restoring facial form and dental function. Fractures are approached through the most minimally invasive and cosmetic approaches possible. In the past, the most common ways to treat fractures of the facial bones involved prolonged wiring of the teeth and utilization of wires to stabilize fractured bone fragments. Today, with time and development of better technology, bones are able to be rigidly fixated with plates and screws and allowed to heal in a stable position, thus alleviating the need to wire the jaw. This accomplishes the ultimate goal of restoring facial form and return to early chewing function.
With the loss of a tooth or multiple teeth, dental rehabilitation with replacement of teeth can be accomplished by several different methods. Dental implants are a long-term option to replace a single tooth or to create a platform for restoration of all teeth. Many of the traditional methods for replacing missing teeth involve shaving down of healthy teeth or rely on the gum tissue for stability.
Dental implants have revolutionized the ability of dental professionals to predictably replace teeth with stability and longevity. Oral & maxillofacial surgeons at BMC have tremendous experience in placement of dental implants, working with patients and their dentists to plan for the placement of the implants, and coordinate care so that a prosthesis can be fabricated to replace one or more needed teeth.
There are many factors that contribute to the appearance of our face and neck as people age. These include gravity, loss, and descent of the fat in the face, loss of skin elasticity, sun damage, habits such as smoking, as well as many other factors. There are a variety of reasons why a person might seek facial rejuvenation such as wrinkles of the forehead, around the eyes or mouth, sagging skin below the jawline, sagging skin of the neck, excess skin of the eyelids, pronounced folds between the cheeks and lips, the appearance of bags under the eyes, or dissatisfaction with the appearance of the nose. Patients may also have functional problems that lead to decreased peripheral vision or problems with breathing through the nose.
No matter what the reason for seeking facial rejuvenation, the goal is to enhance facial appearance and assure that realistic expectations can be achieved. There are a number of procedures offered to address specific patient concerns and it is critical that treatment be individualized for the best possible outcome. Procedures include BOTOX®, facial fillers, blepharoplasty (eyelid lift), brow lift, face lift, neck lift, otoplasty (ear surgery), rhinoplasty (nose surgery) and lip augmentation.
Corrective jaw surgery is a procedure utilized to treat a wide variety of issues with the jaws and teeth. These discrepancies may lead to difficulty chewing, difficulty swallowing, problems with the jaw joint, difficulty with speech, excessive wear on teeth, imbalance of the facial profile, dry eyes, weak chin, and problems breathing. Surgery is performed by oral & maxillofacial surgeons to correct the misalignment and improve the patient's ability to function; and while this is a procedure for functional purpose, there is often a positive change in the facial appearance.
Not everyone who has misaligned teeth or jaw discrepancies require jaw surgery. BMC providers work closely with orthodontists to determine which patients are candidates for surgery, traditional orthodontics, or a combination. Those patients who would benefit from surgery are most commonly placed in orthodontic appliances (braces) to prepare for the surgery as well as to detail the bite after the surgery. The surgery is dependent on the discrepancy and can involve one or both jaws going forward, backward, up, or down.
These operations are planned carefully and by using molds of the teeth, the surgery is performed in our laboratory before the actual surgery. Once this "model surgery" is done, the movements are captured in plastic splints that are placed on the teeth during surgery to help assure precise movements of the jaws and teeth.
Just like orthodontics, this surgery is most commonly performed in a person's late teens or early twenties, but patients of any age who have jaw and dental discrepancy may be candidates for surgery. There are also certain scenarios where early combined surgical-orthodontic therapy can lead to a greater movement of teeth and the supporting jaw than is available with traditional orthodontics.
At Boston Medical Center, the care of patients with oral cancer is a collaborative, multidisciplinary process. Organizing services around each patient, BMC providers bring together the expertise of diverse specialists and manage their patient's care from the first consultation and diagnosis through treatment and follow-up visits all in one location.
What is oral cancer?
Oral cancer starts in the mouth, also called the oral cavity. The oral cavity includes the lips, the inside lining of the lips and cheeks, the teeth, the gums, the front two-thirds of the tongue, the floor of the mouth, and the roof of the mouth. There are several types of cancer that can start in the mouth including: squamous cell carcinoma, slow-growing verrucous carcinoma, salivary gland carcinoma, and lymphomas of the tonsils and base of tongue. Oral cancers are part of a group of cancers commonly referred to as head and neck cancers, and of all head and neck cancers they comprise are about 85% of that category.
Resources for more information:
What are the symptoms of oral cancer?
It is important that you are screened annually for oral cancer; this is usually done by your dentist. If you notice any changes in your mouth or throat between examinations you should contact your dentist or physician. If you notice any of the following you should contact your physician or dentist immediately:
- Difficulty chewing or swallowing
- A white or red patch anywhere in the mouth
- A sore or lesion within the mouth that does not heal within two weeks
- Trouble moving the tongue or jaw
- Numbness in or around the mouth or jaw
- Chronic hoarseness
- Change in how dentures fit
What causes oral cancer?
Oral and pharyngeal cancer continues to pose a significant public health problem. Traditionally, head and neck cancer was considered a disease of older men who abused tobacco and alcohol. Recent studies have implicated the Human Papilloma Virus (HPV) as an inciting factor in some people with oropharyngeal cancer, particularly those people under 45 years of age.
A small percentage of people do get oral cancers from no currently identified cause. It is currently believed that these are likely related to a genetic predisposition.
How is oral cancer diagnosed?
From your first visit to BMC, you will receive highly coordinated, multidisciplinary care that is managed by a BMC Oral and Maxillofacial surgeon -- a doctor who specializes in treating tumors and cancers of the oral cavity and the head and neck area.
Your surgeon will most likely order testing to confirm the diagnosis of oral cancer. These tests may include: Computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). The surgeon may also order a combined PET CT test. All of these tests are important to help the surgeon come up with a diagnosis and a way to stage your cancer. Staging assesses the degree of local infiltration, involvement of regional lymph nodes, and the presence of distant metastases or second primary tumors.
The surgeon may also perform a fine needle aspiration (FNA) to make a tissue diagnosis.
If you have a suspected or confirmed diagnosis of oral cancer, your physicians will use a variety of diagnostic procedures to stage the disease and to determine its severity and spread.
How is oral cancer treated?
At BMC, your cancer care is integrated at all levels including diagnosis, treatment and supplementary therapy. Specialists from medical oncology, radiation oncology, otolaryngology, dentistry, speech/language pathology, and other medical disciplines combine their expertise to provide you with an integrated, individualized treatment plan.
With their depth and range of expertise, our specialists apply a wide array of state-of-the-art techniques to cure patients by removing and killing cancerous tissue. Your plan may include surgery, radiation, chemotherapy, or a combination of these treatments.
Surgery remains the primary method of treatment for cancers of the oral cavity. Our surgeons also use the most advanced techniques; some offered nowhere else in the region. Surgery includes removal of the cancerous tissue, lymph node sampling, and complex reconstruction.
Reconstruction of the lips, tongue, and floor of mouth is frequently performed with microvascular free tissue transfer. This technique optimizes quality of life by restoring function in the shortest time frame by "transplanting" the patient's own tissues. These reconstructive surgeries are complex and labor intensive and require the use of an operating microscope to connect blood vessels in transposed tissues.
Cancer Survivorship Program
A diagnosis of cancer can be a life-altering experience. The BMC Cancer Support Services Program provides a comprehensive set of services to help patients focus their energy on combating and coping with their disease. Designed to improve long-term outcomes and survivorship, these services address a range of medical, social, economic, and emotional needs.
At BMC, we understand that cancer affects patients and families in many ways. We are here to support you during all aspects of care—from diagnosis through treatment and recovery. We offer a comprehensive array of support groups, workshops, lectures, and activities designed with you in mind.
The Head and Neck Cancer Support Group meets monthly in the Moakley building and the schedule and location can be found in our Cancer Support Newsletter.
The oral cavity is a specialized environment of soft and hard tissues that is unique and one of the most dynamic regions in the body. It is the only area of the body that houses teeth (and the specialized structures that form teeth), contains bone, blood vessels, nerves, mucosa (the specialized type of skin that lines the oral cavity, nose, and GI tract), salivary glands, taste buds, and muscle tissue. Any of these structures can produce either benign or malignant pathology, as well as produce the signs of many systemic diseases and general health of a patient. Oral and maxillofacial surgeons must be thorough in their examination and knowledge of the types of pathology that can form in the oral cavity.
There are a number of developmental cysts and tumors that are related to the jaws and the specialized organs that lead to the development of teeth (odontogenic cysts and tumors) that are often asymptomatic. Many times these types of pathology are detected by the careful clinical and radiographic (x-ray) examination that is performed routinely by dentists and dental hygienists. These can also be detected by patients because of growth of the jaws, changes in the bite, loosening of teeth, pain in the jaws, or any other number of symptoms that should prompt patients to seek evaluation by a dental specialist. Once there is suspicion of an odontogenic cyst or tumor and after careful clinical and radiographic examination, a biopsy is often performed and sent to a pathologist that specializes in oral diseases. Depending on the diagnosis, the surgeon will review the pathology with their patient and tailor a treatment to their specific needs. The majority of these cysts or tumors are benign and treatment can range from simple removal to more extensive surgeries requiring reconstruction.
Often, people will have different changes that are noticed themselves or by their dentist or physician. These can range from bumps, white spots, growths, or swellings on the gum tissue, cheeks, or lips. Although these things are often benign, they should not be ignored and should be promptly evaluated by surgeons at BMC's office. With the evaluation, a biopsy is often recommend, or close follow-up with the patient with the assistance of the dentist.
The most serious type of oral pathology is oral cancer and because early detection is critical to successful treatment, lesions of the soft tissues of the mouth will often be biopsied. The most common presentation of oral cancer is a red or red-white patch in the mouth, a sore or ulceration that fails to heal, a hard lump in the soft tissues of the mouth or neck, or changes in sensation in the soft tissues of the mouth, lip, chin, or tongue. These lesions are typically not painful but this does not mean that they should be ignored. Patients should perform self-examination monthly and attend routine dental visits for a more thorough examination.
Many of the injuries and pathology require that the hard and soft tissues of the facial region be rebuilt or enhanced. Tumor surgery (benign or malignant), traumatic injuries, infections, and congenital abnormalities can require different types of reconstructive surgery.
Surgeons at BMC are uniquely trained in the most innovative and state-of-the-art techniques in facial reconstruction, scar revision, wound closure, and other reconstructive procedures. They will take the time to make sure concerns are addressed and treatment is individualized to give patients the best possible cosmetic and functional outcome.
In a perfect world, everyone would sleep soundly and wake rested; but for those suffering with obstructive sleep apnea (OSA), seven to eight hours of uninterrupted sleep is just a dream. From excessive daytime sleepiness and loss of concentration to depression and cardiovascular problems, sleep apnea is a serious medical condition that can be successfully treated by a team of highly skilled surgeons in the Department of Oral and Maxillofacial Surgery (OMFS) at Boston Medical Center.
What is OSA?
During sleep, the upper airway is obstructed by excess tissue in the back of the throat, large tonsils and/or a large tongue. The obstruction causes the diaphragm and chest muscles to work harder than normal. These conditions cause a person's breathing to become interrupted because less air than normal is inhaled. Taking in less air causes a person to wake up, which restarts the normal breathing process.
Those who are diagnosed with sleep apnea generally have 30 of these interruptions during a seven-hour sleep period. In severe cases, breathing may stop for as long as 60-90 seconds and happen up to 500 times per night.
Those who have OSA are often unaware of their condition and think they sleep well because they do not remember waking up. The symptoms that usually lead people to seek help are daytime drowsiness or complaints of snoring and breathing problems observed by a partner. OSA symptoms may include:
- Snoring with pauses in breathing (apnea)
- Excessive daytime drowsiness
- Gasping or choking during sleep
- Restless sleep
- Problem with mental function
- Poor judgment/can't focus
- Memory loss
- Quick to anger
- High blood pressure
- Nighttime chest pain
- Problem with excess weight
- Large neck (17" around in men, 16" around in women)
- Airway crowding
- Morning headaches
- Reduced libido
- Frequent trips to the bathroom at night
Diagnosing Sleep Apnea
If you have several of these symptoms, you should talk to an oral and maxillofacial surgeon (OMS) for a complete examination and an accurate diagnosis.
Treatment of Sleep Apnea
If you are diagnosed with sleep apnea, your OMS will help you decide which treatment is best for you. Depending on whether your OSA is mild, moderate or severe, this can range from lifestyle modification to oral appliances to a C-PAP device which is a machine that helps a person breathe more easily during sleep.
If a patient is are diagnosed with mild sleep apnea, your doctor may suggest you employ the non-medical treatments recommended to reduce snoring including weight loss or changing your sleeping position to your side. In mild cases, these practical interventions may improve or even cure snoring and sleep apnea.
C-PAP (Continuous Positive Airway Pressure) and Bi-PAP (Bi-Level) Devices
A C-PAP device is an effective treatment for patients with moderate OSA and the first-line treatment for those diagnosed with severe sleep apnea. If you stop using the C-PAP or Bi-PAP, your symptoms will return. Although C-PAP and Bi-PAP are often the first treatments of choice, they may be difficult for some patients to accept and use. If you find you are unable to use these devices, do not stop without first talking to your doctor.
Appliances and C-PAP are treatments, but not cures. At BMC, we are proud to provide patients with curative options. Recommended for patients age 16 and above, BMC surgeons perform the highest number of such surgeries in New England. Now with quicker operating times, shorter hospital stays and fewer complications, modern day jaw surgery is a viable option for patients when C-PAP treatment fails to relieve symptoms or is not well tolerated.
To find out if you are a good candidate for surgery, you will have a series of appointments and tests with our surgeons. These include and evaluation where the physician locates the obstruction by assessing your facial structures including the nose, throat, jaws, palate and chin areas. Additional 3D cat scans, computer tracings and simulations are also done and together form an individualized treatment plan.
Once those are complete, your surgery will be scheduled.
The hospital stay is typically two to three days with the first two weeks following surgery requiring limited activity. Normal life can resume within two to four weeks, barring very strenuous tasks like the gym and contact sports.
Before and After
The temporomandibular joint (TMJ) is the small joint in front of the ear where the lower jaw fits in to the base of the skull. Between the top part of the jaw (the condyle) and the base of the skull (fossa) is a specialized disk similar to the meniscus of the knee. This joint allows people to open and close their mouth. Surrounding the joint are a number of muscles that facilitate opening and closing of the mouth.
TMJ disorders are not uncommon and can present with a variety of symptoms such as ear pain, headaches, limitation in the ability to open the mouth, changes in the bite, and increasing space in-between the front teeth of the upper and lower jaw.
One of the most common complaints about the TMJ is popping and clicking within the jaw joint. This is caused by the disk (meniscus) in the middle of the joint being positioned in front of the top part of the lower jaw (the condyle). The popping or clicking occurs when the disk is positioned in front of the condyle and on opening the mouth, the condyle slides on to the disk resulting in the noise. This positioning of the disk is more of an irregularity in anatomy than true bad positioning as it is found in almost 40% of humans. The time when this position becomes difficult is when it causes restriction of motion of the jaw, pain, or inflammation. In these cases, it is often self-alleviating with time, but there are several tactics used by surgeons to help treat this condition when it becomes pathologic. Typically surgeons begin with conservative therapy, medical management, sometimes splint therapy, physical therapy, and in only 10-15% of patients require surgical intervention.
The joint can also develop arthritis which can lead to a hole in the disk. This can cause a grating or grinding sound with opening and closing and can range in symptoms from just noise to pain and limitation of opening. This is also treated conservatively as mentioned above and rarely is cause for surgery.
In some patients, trauma, osteoarthritis, rheumatoid arthritis, or other conditions can cause severe restriction of movement of the joint. In these cases, the jaw joint can fuse with either scar tissue or a bridge of bone can form between the jaw and base of skull. This would necessitate surgical intervention to repair, however the condition is quite rare.
The most common problem and what people most commonly refer to as "TMJ" is an inflammation and spasm of the muscles that surround the jaw joint and facilitate opening and closing referred to as myofascial pain. This is often caused by grinding of the teeth at night, or clenching of the jaw during the day. The clenching and grinding has many factors and can be related to stress, medication, ergonomics, habits such as chewing gum, jaw injuries, how the teeth fit together, or a host of other causes that are not yet identified.
This spasm can lead to headaches, restriction of motion, severe and diffuse jaw pain, a shift in the bite, as well as back, and neck pain. It can also lead to inflammation within the jaw joint itself which serves to confuse the clinical picture. Due to the inflammation and muscle spasm, the mainstay of treatment is anti-inflammatory medication, muscle relaxing techniques, heat, rest, and typically a muscle relaxant. In people who are reluctant to try these treatments and continue to have significant pain, headaches/migraines, or other adverse effects to their daily life, can often get relief from BOTOX® in to the areas of muscle spasm.
Injury to the nerves in the face or mouth can occur for a variety of reasons including facial trauma or a patient's facial structure's predisposition to common dental procedures. When this happens, people experience numbness or pain in their face. Oftentimes, injuries heal within months. When they don't, nerve repair surgery at BMC can provide significant relief.
The decision to repair a damaged nerve is individual and depends on the impact to the patient's daily life, nature of the injury, and time since the injury occurred, but they can often expect 60-80% of feeling to return within one year and immediate relief from any present pain.
In many people, the third molars (wisdom teeth) are not functional teeth, meaning that they are not useful in chewing. Depending on their position in the mouth, they can be difficult to keep clean. Debris and bacteria can gather around wisdom teeth causing pain, inflammation, and cavities. Additionally, wisdom teeth are frequently blocked from entering the mouth because of lack of space — a condition known as impaction. More than 90% of the population has or has had at least one impacted tooth. Varying degrees of impaction in which teeth are completely or partially covered by bone and gums can cause multiple problems if not removed. Problems arising from impacted teeth include pain, infection, loss of bone and gums, damage to adjacent teeth, and can contribute to general health problems.
Removal of wisdom teeth at a young age can prevent long-term and irreversible damage to the gums and supporting tissue around the functional second molar. Between age 16-21 is an ideal time to have wisdom teeth removed because surgeons at BMC can predict whether or not there is likely to be a problem at some point, the patients recover quickly, there is less risk to nerves near the wisdom tooth, and healing is better.
A short consultation involving an oral and radiographic exam should be done to evaluate the position of the wisdom teeth and potential issues. A surgeon will explain the procedure and the recovery from wisdom teeth extraction, as well as answer any questions. Removal of wisdom teeth is an outpatient procedure done routinely in the office under intravenous sedation.