What does oral and maxillofacial surgery involve?

What the specialty covers

Oral and maxillofacial surgery is surgery of the oral and facial region. It involves the diagnosis, surgery and treatment of diseases, injuries and defects of the mouth, gums, teeth and jaws — both how they function and how they look. Oral and maxillofacial surgeons is the service page, and specialist care sets out the other dental specialties alongside it.

The scope is wider than most people expect, and it runs from routine to major.

The range of work

Dento-alveolar surgery — the most common form, including wisdom teeth and other impacted teeth. Wisdom teeth, and for the recovery, how long does it take to recover from wisdom teeth surgery? — which also covers dry socket, the complication most people meet.

Oral pathology — including cysts of the jaws. Persistent ulcers, lumps and patches are assessed here too: the cause of mouth ulcers and their usual treatments explains the three-week rule that triggers the referral.

Implantology — replacing missing teeth with titanium screws implanted in the jawbone. Full mouth rehabilitation with implants may be performed, and where there is insufficient bone to support implants, bone grafting procedures may be required — bone grafting. See also dental implants, what you need to know about dental implants, who should I see for dental and teeth implants?, conventional and immediate implants, and all-on-4 dental implants. Where the choice is between an implant and something else, implant versus bridge for single tooth replacement and bridges, implants or dentures compare them honestly.

One thing worth stating plainly: untreated gum disease is the most common reason an implant is not an option, because the bone that would hold it has already gone. Periodontal (gum) disease and when do you need deeper cleaning? cover why that happens and what stops it.

Corrective jaw surgery (orthognathic surgery) — undertaken in conjunction with an orthodontist, to align the jaws in proper relationship and ensure good bite and facial proportions. What is orthognathic surgery? sets out the full 18 to 24 month sequence; jaw surgery is the service page; and what can I eat and drink following jaw surgery? covers the weeks afterwards.

That collaboration is not optional. Orthognathic surgery moves bone; orthodontics moves teeth, and the teeth have to be positioned correctly before and after the jaws are repositioned. It is a joint treatment plan running over a year or more. Orthodontists, orthodontics, and complex dental cases: what happens when multiple specialists need to collaborate.

Oral cancers and tumours — diagnosed and treated by oral and maxillofacial surgeons. Procedures involve resecting tumours of the oral cavity and reconstructing with tissue taken from elsewhere in the body, such as the forearms or legs. Oral cancer: how your dentist can help with early detection, oral cancer: signs, risk factors and how your dentist can help, and what are the causes, symptoms and treatment of mouth cancer?. Treatment to the head and neck frequently causes long-term dry mouth, which changes dental care permanently.

Temporomandibular joint (TMJ) dysfunction — treatable with surgery in certain cases, which may involve complete joint reconstruction with replacements. This is the end of the TMD treatment spectrum, considered only where conservative management has not succeeded. Start at the other end: what is the difference between TMD, TMJ and bruxism?, what are the most common symptoms of TMD?, can TMD be fixed?, and TMD and teeth grinding.

Facial trauma. A knocked-out or displaced tooth, a fractured jaw or a facial laceration is the acute end of this specialty. For a dental injury that is not a hospital matter, emergency dentistry and chipped and cracked teeth. Much of it is preventable in sport — should I wear a mouthguard while playing sports?, getting a new mouthguard: a trip to the chemist or the dentist?, and sports mouthguards.

When to go to hospital rather than book

Most of what is described here is planned, referred work. Some of it is not. Go to a hospital emergency department, or call 000, if you have:

An infection that begins in a tooth can spread into the tissues of the face and neck and compromise the airway. Why are dental abscesses so painful?, what is a tooth abscess? Should I have it treated?, and can a dental abscess affect your general health? explain why that is not a wait-and-see situation.

Coordination of care

Whether you need simple extractions or major surgery, your surgeon will liaise with your general practitioner and any other medical specialists to coordinate care and ensure the procedure is completed safely and reliably. Complex dentistry and why would I need to see a dental specialist? cover how that referral works in practice; how important is communication in dentistry? is the argument for making sure it does.

Oral and maxillofacial surgeons have admitting rights to many private hospitals, so treatment can be provided in an accredited hospital facility under general anaesthesia where required. Where sedation rather than hospital anaesthesia is appropriate, sleep dentistry and sleep dentistry costs: what does sedation add to your dental bill?. If anxiety is the reason you have been putting a referral off, dental anxiety and how can I ease my anxiety about visiting the dentist? are the place to start.

All surgery carries risk, and no outcome is guaranteed. Discomfort after oral surgery is expected and managed rather than avoided altogether — I've just had oral surgery. What can I expect during recovery? sets out what normal healing looks like and which departures from it need reporting.

Medicare and health fund rebates

This is genuinely useful and widely misunderstood, because most dental treatment attracts no Medicare rebate at all.

You can receive a Medicare rebate for:

You can receive a Medicare or health fund rebate for any aspect of treatment classified as medical, including:

The distinction is between dental and medical classification, not between dentists and doctors. Because oral and maxillofacial surgeons hold both qualifications and much of their work is medical in nature, a portion of it falls under Medicare in a way that ordinary dentistry does not. It is worth asking specifically which parts of a proposed treatment are classified as medical before you assume the whole fee is out of pocket.

Published fees for dental items are in the price guide; understanding your treatment covers how to read a written plan and what to ask about it; and for the specific figures people most often want in advance, what costs are involved with wisdom teeth removal? and how much do dental implants cost?

Payment plan options are available. Where a plan is advertised as interest free, that describes the plan term only — a deposit may be required, an establishment fee and ongoing account fees may apply, and charges can apply if the balance is not cleared within the agreed period. The applicable terms depend on the provider and the amount financed, and are set out in writing before you commit — ask what the deposit and the establishment fee are, in dollars, and what the total will be by the end. Payment Plans.

What an oral and maxillofacial surgeon is

They undergo continuous study for 12 to 14 years, and hold:

Some hold further Masters degrees depending on their sub-specialty interest — paediatric maxillofacial surgery, or surgical anatomy, for example. For children's care generally, paediatric dentists and children's dentistry.

Most work in public and private hospitals, where they reconstruct facial form and function after facial trauma. Patients with facial fractures, and those with congenital deformities such as cleft lip and palate, have their reconstruction carried out by an oral and maxillofacial surgeon.

Registration

They are registered specialists with the Dental Board of Australia and the Royal Australasian College of Dental Surgeons, on successfully completing their final specialty examinations (FRACDS).

Always check the AHPRA website to confirm the registration of a specialist. It takes two minutes, and “specialist” is a protected title with a specific legal meaning. The practice's registered specialists are identified as such within the full team. If a surgical plan does not sit right with you, a second opinion is a reasonable step before committing.

Common questions

Do wisdom teeth have to come out if they are not causing any trouble?

No — and this is the question where the published guidance most clearly contradicts what people expect to be told.

The most recent systematic review is candid about the state of the evidence. Cochrane's 2020 review of surgical removal versus retention for asymptomatic, disease-free impacted wisdom teeth concludes: “Insufficient evidence is available to determine whether asymptomatic disease-free impacted wisdom teeth should be removed or retained. Although retention of asymptomatic disease-free impacted wisdom teeth may be associated with increased risk of periodontitis affecting adjacent second molars in the long term, the evidence is very low certainty.” Its advice is for shared decision-making rather than a default: “patient values should be considered and clinical expertise and local and national guidance used to guide shared decision-making.”

The best-known guideline goes further, and its age and origin both matter. NICE technology appraisal TA1, published on 27 March 2000 for the United Kingdom NHS — it is not Australian guidance and has no legal or funding status here — recommends that “the practice of prophylactic removal of pathology-free impacted third molars should be discontinued in the NHS”, and that “surgical removal of impacted third molars should be limited to patients with evidence of pathology.”

The pathology it lists is specific, and is a reasonable checklist to take into a consultation: unrestorable decay; non-treatable pulpal or periapical disease; cellulitis, abscess or osteomyelitis; internal or external resorption of the tooth or the tooth next to it; a fractured tooth; disease of the follicle including a cyst or tumour; a tooth obstructing planned surgery or reconstructive jaw surgery; and a tooth within the field of a tumour resection.

On the most common real-world trigger — the gum flap over a partly erupted tooth becoming infected — TA1 draws a line at the second episode. It states that “a first episode of pericoronitis, unless particularly severe, should not be considered an indication for surgery. Second or subsequent episodes should be considered the appropriate indication for surgery.” It also notes that plaque around the tooth is a risk factor “but is not in itself an indication for surgery.”

If I keep them, what does “monitoring” actually mean?

Ordinary dental care, plus knowing that these particular teeth are on the list to be looked at. Cochrane defines retention as “monitoring the status of wisdom teeth” and notes that the approach “requires individuals to have regular dental reviews or ‘checkups’.” Its closing advice is that if the decision is to retain, “clinical assessment at regular intervals to prevent undesirable outcomes is advisable.”

It does not mean a more elaborate routine. NICE TA1 is explicit that “the standard routine programme of dental care by dental practitioners and/or paraprofessional staff need be no different, in general, for pathology-free impacted third molars.”

What is worth doing is making the monitoring explicit rather than assumed. Ask for the position of each wisdom tooth to be recorded, ask what specifically would change the recommendation, and ask when the radiograph would next be repeated. A decision to retain that nobody revisits for a decade is not really a decision.

Two facts of timing that make the conversation easier. Wisdom teeth generally erupt between the late teens and the mid-twenties — Cochrane's background gives 17 to 26 years, NICE gives 18 to 24 — and impaction is common rather than exceptional, with a worldwide impaction prevalence of 24% cited in that review. Having impacted wisdom teeth is not in itself a problem to be solved.

What is the actual risk of nerve damage from having a lower wisdom tooth out?

Small overall, and very unevenly distributed — which is exactly why the radiograph is taken before the decision rather than after it.

A systematic literature review of inferior alveolar nerve injury after lower wisdom-tooth removal reports the incidence of nerve paraesthesia as “about 0.35 – 8.4%” across studies, with 1% to 20% temporary and 0% to 2% permanent neuropathy reported in the literature it cites, and states that “the risk of permanent injury, in which sensory impairment lasts longer than 6 months, is less than 1%.”

The breakdown is the useful part. The same review reports an overall incidence of nerve damage of 2.5% per tooth removal, and the figure changes sharply with how close the nerve runs to the roots on the radiograph: 0.8% where the nerve is “distant”, 0.9% where it is “close”, and 11% where it is classed as “intimate”. Impaction angle matters too — highest with horizontal impaction (4.7%) and lowest with vertical impaction (0.9%).

What that means for your appointment. Your own number is not the average; it is the one that follows from where your nerve sits and how your tooth is lying. It is entirely reasonable to ask which of those categories applies to you, whether further imaging would change the estimate, and what the alternatives are if the proximity is intimate. Those figures come from an international review rather than from this practice, and they are consent information rather than a prediction.

My own dentist could take them out. Why would the referral go to a surgeon?

Because the difficulty of the case, not the title of the practitioner, is what decides it — and difficulty is assessable in advance.

The things that push a case toward referral are visible on the imaging and in your history: a lower tooth lying horizontally or with roots close to or wrapped around the nerve, given the 11% figure above; a tooth deeply covered by bone; a medical history that complicates bleeding, healing or anaesthesia; and any plan needing hospital facilities. As set out above, oral and maxillofacial surgeons hold admitting rights to many private hospitals, so treatment can be provided in an accredited hospital facility under general anaesthesia where that is required.

The things that do not decide it are how anxious you feel or how much the tooth is aching. Both are real and both are manageable — see sleep dentistry and dental anxiety — but neither is a reason on its own to move the surgery to a different practitioner.

A reasonable way to ask. What makes this case straightforward or difficult? What would change if it turned out to be harder than expected once it began? And, if a referral is proposed, what specifically about the imaging prompted it? A clear answer to the last question is usually the whole justification.

Related reading

Practical details

Written by Dr Ricky Kumar.

Smile Solutions, Level 1, 220 Collins Street, Manchester Unity Building, Melbourne VIC 3000 — getting here. Phone 13 13 96, contact us, or theteam@smilesolutions.com.au. Monday–Friday 8.00am–6.00pm, Saturday 8.30am–1.30pm, Sunday by appointment.

Specialist registration can be verified on the AHPRA register, or by calling 1300 419 495.

The wisdom-tooth evidence in the questions above is from Cochrane review CD003879.pub5 (2020), NICE technology appraisal TA1 (United Kingdom, 27 March 2000 — not Australian guidance), and a systematic literature review of inferior alveolar nerve injury published in the Journal of Oral & Maxillofacial Research (2014). None of those publishers is connected with us.

Published 16 November 2018. Rebate eligibility depends on individual circumstances and current schedules — confirm with Medicare and your fund. All surgery carries risks that should be discussed with your surgeon. Payment plan terms are set by the credit provider and change; confirm current terms directly before you commit. General information only; it does not replace advice from your treating practitioner.

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