A Significant Medical History

Oral & Maxillofacial Surgery

Glasgow has, over the past 50 years, led the development of the specialty of Oral and Maxillofacial Surgery (OMFS) in the UK. The specialty in the UK traces its roots directly to the pioneering dentists and surgeons who managed the horrendous facial injuries in the first and second world wars. In the UK, the specialty of Plastic Surgery was born and combined with surgeons with a dental training to form Plastic and Maxillofacial Surgery units.

This was first located in Ballochmyle House (1940) in Ayrshire and then it moved to a purpose-built unit in Bearsden on the outskirts of Glasgow, namely Canniesburn Hospital which was opened in 1967. This Hospital remained open and working well until 2003, when the Regional Maxillofacial Unit moved to the Southern General Hospital and the Plastic Surgery Service moved to Glasgow Royal Infirmary (see Burns and Plastic Surgery).

During the period of 1940 – 1967, the specialty of Oral Surgery was developed out of the Hospital Dental Service. Some of the early pioneers in the specialty were qualified in both medicine and dentistry, but the majority were dentally qualified and gradually expanding their surgical repertoire. The British Association of Oral Surgeons was founded in 1962.  By the 1970s, many of the leading surgeons recognised the benefits of obtaining dual qualifications and the advantages of a more formal general surgical training, and by the mid-1980s, a dual qualification was mandatory for consultant appointments in the UK.

In 1994, the specialty, by then known as Oral & Maxillofacial Surgery, became a fully-fledged member of the Senate of Surgery and also one of the nine (now ten) recognised UK surgical specialities. Training was regulated by the Royal College of Surgeons of England and a specialty FRCS examination in Oral & Maxillofacial Surgery was pioneered by the Royal College of Surgeons of Edinburgh in 1984. This has become the Intercollegiate Examination- a key landmark for the completion of specialist training.

Initially the hospital dental surgeons took on minor oral surgery procedures and assisted in the reconstruction and management of facial trauma particularly, utilising their skills with dental materials, dentures and other dental appliances. As these individuals become more surgically skilled, they gradually expanded their role, taking on the management of facial bone fractures and facial deformities. In the 1950s, 60s and 70s, much of this work was done with the aid of dental appliances and external fixation devices. For this reason, the role of the maxillofacial/dental technician within the service was central. Inevitably, as the role of the surgeons expanded, this led to not only very productive collaborations with other specialities but also conflicts and turf wars. Happily, the speciality is now more stable, the conflicts are reducing and the repertoire of the speciality is wide and interesting.

Currently the specialty training after the acquisition of both medical and dental qualifications is five years following the completion of Core Surgical Training or six to seven years on a run through training programme, which incorporates the core surgical training curriculum.

The speciality now provides surgical care for a wide range of conditions of the head and neck region working closely with our dental colleagues and other surgical specialities - particularly ear, nose and throat surgery (ENT), neurosurgery, ophthalmology, plastic surgery. In the 1970s and 1980s we pioneered close co-operation with neurosurgery, ophthalmology, paediatrics and ENT, with joint clinics wherever appropriate.

Although initially set up with a central unit at Canniesburn Hospital  and independent  consultant led services in the surrounding health boards, there has been a strategic move to centralise all major operating in the West of Scotland at the Regional Maxillofacial Unit, based in the Queen Elizabeth University Hospital in Glasgow. The service now provides a diagnostic and management service for head and neck oncology, salivary gland diseases (including minimally invasive techniques), soft tissue and bony facial trauma, the surgical management of temporomandibular joint disorders, and all aspects of the management of congenital and acquired facial deformity. The speciality is a key component of the national cleft lip and palate service, the craniofacial service, and the skull base oncology service, as well as the head and neck vascular anomalies service. In addition to the adult side of the provision of care there is now a comprehensive paediatric service based at the Royal Hospital for Children.

The relationship between NHS Oral and Maxillofacial surgeons and our Academic colleagues based in the dental schools has been at times strained. As the specialty of Oral and Maxillofacial Surgery has strengthened its medical and surgical links, those with our dental colleagues have weakened. As the role for hospital based dentists has been lost, a new dental speciality of Oral Surgery has been created aiming to provide minor oral surgery services both in the community and hospital settings and this has culminated in the formation of a new British Association of Oral Surgeons, created from the British Association of Surgical Dentists. As a dual degree became a requirement for those specialising in Oral and Maxillofacial Surgery, an attempt was made to bridge the gap with the short lived creation of a speciality of Academic Oral & Maxillofacial Surgery, creating a cohort of dentally qualified surgeons who were expected to lead the academic development of the speciality and be based in dental schools with an extended surgical remit.

The University of Glasgow has played a significant role in the development of the specialty in Glasgow. Initially working as single entity, Oral Surgery based at the Dental School in Sauchiehall Street  and the Hospital based Oral and Maxillofacial Surgery service provided common clinics and surgical access. The chair in Dental Surgery (founded in 1951) was converted into the Chair in Oral Surgery in 1977. David McGowan held the post during the period 1977-1999 and specialised in dentoalveolar surgery and the dental management of patients who had previously suffered with rheumatic heart disease. He was superseded in 2003 by Ashraf Ayoub who completed his Academic Oral & Maxillofacial Surgery Training in Glasgow. He continues in post with operating access at the Regional Maxillofacial Unit at the Queen Elizabeth University Hospital. As the specialty has become more aligned with the wider medical community, stronger links are being forged between the department and the undergraduate medical school.

From the description above, it is clear that there has been a significant expansion and development of the specialty both nationally and locally. This has led to the growth of a stronger and also more adaptable specialty, with enhanced skills and training immeasurably improving patient care and outcomes for the patients. Whilst the development of the specialty has continued nationally, there is no doubt that Canniesburn Hospital and now the service based at the Queen Elizabeth University Hospital Glasgow have played a major role in leading many of these changes. The list of consultants appointed to Canniesburn and also at the Queen Elizabeth University Hospital is shown below.

The early work of Stephen Plumpton laid the foundation for two giants of our specialty, namely Derek Henderson (at Canniesburn Hospital 1969-1975) and Khursheed Moos (at Canniesburn 1974 – 2000), to make the Oral and Maxillofacial Surgery Service at Canniesburn world famous.

• Derek Henderson developed a highly productive working relationship with Ian Jackson, consultant plastic surgeon, who eventually found fame and fortune in the USA. Between them and amongst other things, they developed the Le Fort 11 maxillary osteotomy. Derek also significantly changed the pattern of management of trauma locally, as well as developing classification systems that were utilised for the next 30 years. He subsequently moved on to St Thomas’s Hospital London, served as a council member of the Royal College of Surgeons’ dental faculty and was President of The British Association of Oral and Maxillofacial Surgeons (1994). His time in Glasgow gave him the foundations for his seminal publication “A Colour Atlas of Orthognathic Surgery” (1986) which is still used today.
  
  

• Khursheed Moos joined Derek in 1974 and remained at Canniesburn until he retired in 2000. He developed the reputation of the clinical service and training programme forming strong links locally and abroad. He nurtured numerous trainees through the programme and many have gone on to be leaders in the speciality, producing at least four British Association of Oral and Maxillofacial Surgery presidents, numerous council members, examiners and heads of department.

The academic output of the unit grew, with the fruits of clinical collaborations with Ophthalmology and Neurosurgery being frequently seen in the literature. The introduction of a comprehensive Oral and Maxillofacial course running alternate years, with the final day being devoted to live operating, cemented the international reputation of the unit and laid the foundation for many long lasting friendships and collaborations.

At this time the service revolved around trauma, orthognathic (jaw) and craniofacial surgery, while all the head and neck oncology was performed by the plastic surgeons. The service was significantly innovative being very early adopters of distraction osteogenesis, extra- and intra- oral osseointegrated implants, with continued transcranial surgery for craniosysnostosis and complex disorders which made it an exciting time intellectually and surgically. This was added to by a forward looking technical laboratory, initially led by Matt Orr and Walter Smith and then by Fraser Walker, who remains in post. These individuals introduced the use of stereo lithographic models, acrylic and titanium cranioplasties, and more accurate, computerised orthognathic planning, as well as pioneering the fabrication of a variety of facial prostheses. Many of the technologists took on Academic Training for MSc and PhD degrees, providing a useful background to research for the sub-specialities.

During this time, Khursheed Moos was ably supported by Amir El Attar, who was an excellent, caring all round surgeon who acted as the perfect foil to his colleague’s frenetic workload and international travel. When Amir retired, he was replaced by Graham Wood, already an established consultant in North Wales with a wide ranging head and neck oncology practice. 

The impending closure of Canniesburn Hospital facilitated the centralisation of the slightly disparate services within the city. Derrick Russell, who was the consultant at the Victoria Infirmary, assumed the role of clinical director of the unified service. He had been joined by John Devine who led the development of the head and neck oncology service. David Koppel was appointed to replace Professor Moos in 1999.   Professor Moos, who had been awarded a personal chair at the University of Glasgow and an OBE for his contributions, continued to supervise students at the Dental School and teach internationally until 2015.

The new unit opened at the Southern General Hospital in 2003, located within the School of Psychology and Neurosciences Sciences. The service provided by Harry Critchlow at Stobhill Hospital and the Royal Hospital for Sick Children, Yorkhill was taken over by Mark Devlin, who also took over Peter Raine’s cleft lip and palate practice.

These years saw a revolution in the range of practice and the development of a vision for the service based on subspecialisation, team working and shared care both within the specialty and with colleagues from other specialties. The head and neck oncology service now offers comprehensive care for Glasgow, and a shared care model for all major cases and reconstruction for the West of Scotland Health Boards (Forth Valley, Lanarkshire, Ayrshire & Arran and Dumfries and Galloway). Joint multidisciplinary meetings are held regularly, involving all the involved specialities and professionals. The consultants appointed to the surrounding health boards have joint appointments at the regional Maxillofacial Unit in Glasgow, with varying day to day commitments to the service, but there is a shared regional on call system with all consultants participating in the out of hours service at the new Queen Elizabeth University Hospital, Glasgow.

In 2004, David Koppel took over as Clinical Director and led the department during a period of continued expansion, sub-specialisation and major development. The department expanded on the foundations that John Devine laid at the Victoria Infirmary, along with the work done by the head and neck oncology consultants in the surrounding health boards, with the appointment of dedicated Oral and Maxillofacial surgeons who had sub-specialised in oncology. This culminated in the whole of the head and neck oncology service being jointly managed with ENT at the Queen Elizabeth University Hospital. Within a ten year period, the management of head and neck oncology had undergone a massive change in the delivery of care. Integrated, streamlined multi-disciplinary clinics and meetings are held at various sites to minimise patient travel. However, the planning and delivery of major operating has been centralised, with the significant adoption of 3-dimensional planning techniques, and patient specific implants and solutions.

The department had seen the rise in the use of face transplants in the various centres in the world, and felt that it had all the skills and attributes both surgically and in the wider health care team required for such work. In order to pursue this ambition, a senior trainee (Major Colin Maciver) spent a year in the world renowned transplant unit in Paris. On his return and appointment as a consultant, the unit continued to develop its skills with cadaveric workshops, support from UK Blood and Transplant, as well as multidisciplinary training. The unit would have been the first in the UK to deliver this ground breaking treatment but the Scottish Government through the National Service Division did not support this ambitious and important development.

Mark Devlin (who had completed his OMFS training in Glasgow and a cleft lip and palate fellowship in South Thames) developed the Glasgow Cleft Lip and Palate service, which was rationalised initially to a national, two centre service and then in 2016 to a national service, with one surgical centre in Glasgow with outreach clinics in major cities. The Cleft service currently has two surgeons in post – Craig Russell (Plastic Surgery) and Mark Devlin, who share the whole remit of the care for cleft patients.

Trauma, a subspecialty often neglected and treated by everyone, was an area that the unit felt ought to be led and principally delivered by surgeons with a particular interest, and to this end Ian Holland was recruited from Forth Valley in 2006. He was joined in 2018 by Mark Ansell who is also part of the head and neck oncology team.

The Craniofacial and Vascular Anomalies Services were developed by David Koppel and he was joined by the appointment of Moorthy Halsnad in 2015. The craniofacial service provides comprehensive paediatric and adult care for the full range of congenital and acquired craniofacial anomalies. Initially, the neurosurgical service was delivered with Rab Hide, and on his retirement the paediatric aspects were delivered by Jennifer Brown and the adult service by Bill Taylor. As the oncology service developed, Jeremy McMahon took major responsibility for the oncological skull base work, and now a regular MDT meeting takes place with neurosurgical, ENT, oncology and allied health care professionals. The paediatric service is currently led from a neurosurgical perspective by Raju Sangra, supported by Tony Amato-Watson.

In 2014 David Koppel stepped down as lead clinician to concentrate on his roles as Standing Advisory Committee chairman and chairing the Organising Committee of the 2021 International Association of Oral & Maxillofacial Surgery meeting. He was replaced by Colin MacIver who remains in post.  John Devine left to develop a service in Abu Dhabi and he was eventually replaced with the appointment of James McCaul who leads the academic development of the department.

In the past 20 years the Oral and Maxillofacial Service in the West of Scotland has metamorphosed from individual surgeons working in relative isolation, to a truly integrated team of 18 consultant surgeons working in subspecialist teams across a variety of health boards to provide the full range of contemporary Oral and Maxillofacial care.
Professor David A Koppel

Images provided by Professor Kopel

20th Century

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