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Maxillofacial surgery can present some of the most complicated procedures seen in dentistry. MED talks to Dr Steven Liggins, head of the maxillofacial department at Sheikh Khalifa Medical City (SKMC) about the disciplines needed to tackle trauma.

It takes 20 years of training to become a maxillofacial surgeon - how demanding is that as a process?

It is a very difficult option to pursue because it is very expensive. When I went through my training I had to support myself entirely through medical school while supporting a young family. It is becoming very difficult for young students to get the length of training that is required. They are always looking at ways to shorten it if they can.

Where did you train?

While I was training in my first consultant appointment, I was in the Royal Navy. I first came to this part of the world on a royal tour with Charles and Diana in 1983, when they visited Oman and some of the other Gulf States. I was the doctor on board the ships, but as a general doctor not as a maxillofacial surgeon. I then became a maxillofacial surgeon in the royal navy - in fact I was their only dual-qualified dual-fellowship maxillofacial surgeon. I then went to the teaching hospital in Birmingham and became lead clinician in facial deformity and trauma. I spent five years there and then decided to change tack and was recruited here. My specialty is facial deformity and facial trauma.

What added skills do maxillofacial surgeons have that dentist don't?

You have to understand that maxillofacial surgery is really split into two different categories. There is oral surgery and there is maxillofacial surgery. Oral surgery is a specialty of dentistry, maxillofacial surgery is specialty of surgery requiring a dental qualification. We assigned medical directives in Europe in the early 80s, which rationalised the training and the requirements for each specialty. The UK has just come into line with the Europeans. For consultant appointments across the UK and Europe, to be a maxillofacial surgeon, you're required to be dual qualified.

How do the two disciplines combine in a practical sense?

When you are dealing with major craniofacial abnormalities you're in a big surgical area, and you need to have skills in both surgery and dentistry. The dental skills are required to know how jaws are put together and the surgical skills are needed to know how to keep the patient alive while you are building the face. The longest operation I have performed lasted 22 hours.

At what stage does deformity become an issue of cosmetics?

Deformity is, after all, a relative thing. You can live with a mild degree of deformity, but as patients become more educated they seek treatment for more mild irregularities. We try for all our operations to be cosmetically pleasing, but where patients seek cosmetic treatment there really is little functional abnormality. Sometimes the abnormality in function can be psychological and we assess the patient along with a psychiatrist, but usually the crossover is deemed to be causing a functional impairment or something has happened to the patient - whether it is a birth injury or a traumatic injury. Sometimes, in the minutiae, it is very difficult to see what is a cosmetic and what is a functional case.

Can you give an example?

We get a lot of referrals from our orthodontic colleagues, for orthognathic surgery. They are often referred to the maxillofacial surgeon because their
occlusion isn't correct. When you actually ask the patient why they came to the orthodontist it is very rarely a problem with their bite. They all say that they have a big lower jaw, or a small upper jaw, or all their teeth stick out. From a patient's perspective, a lot of these procedures are done for cosmetic reasons.

What sort of dental trauma do you see most often at SKMC?

In the UK the epidemiology of trauma is different to the UAE. We see a form of causation similar to that seen in the UK in the 60s and 70s, insomuch as that a large proportion of it is related to road traffic. In the UK this has been ameliorated a great deal by the mandatory use of seatbelts. Of course, seatbelts should be used here, but the uptake rate appears to be lower. We get a higher incidence of road traffic related accidents here than we do in the UK. In the UK it is mainly now interpersonal violence that causes facial trauma. There are also a lot of industrial accidents in the UAE because of the high level of construction that is underway.

How busy is the maxillofacial department at SKMC?

For major facial trauma we get one or two cases a week. These are very major conditions that often require joint procedures with our neurosurgical colleagues. These are operations that can be between six and 10 hours long. We get a considerable amount of major trauma at SKMC. We also treat, on average, about two facial deformity cases a week. These take months of planning and work-up before we take them to theatre. We have three consultants and two other doctors - we treat major trauma cases and facial deformity cases. It is a busy department offering as good a treatment as anywhere in the world in our specialty.

Do your procedures require a lot of referral consultations?

We have to work closely with our orthodontic colleagues as without them it is impossible to achieve a stable result. We have to look at the position of the teeth, the jaws - one of the most important things is asking the patients what they want to achieve. It is often the thing that is missed and that is the same with medical treatment.

Currently, how well served is the UAE for maxillofacial surgery?

In the UK there is one maxillofacial consultant for every 500,000 patients. Here we have a pretty similar number. We've probably got about 15 in the UAE. Of the oral surgeons, it is difficult to get precise figures because a lot of the surgeons work in the private hospitals doing smaller cases - we are probably taking about maybe 50 or so in the whole of the UAE. Accurate numbers are difficult to come by. We treat national patients in SKMC through the state system and we treat expats through their insurance companies. Everybody that comes into SKMC, we treat. The billing is left to our accounts department to sort out. From a humanitarian point of view, we treat all patients.

What do you enjoy about the work?

It is a fantastic job. I wouldn't really want to be anything else. The difficult thing involved in it I suppose is that it is physically demanding job. To operate and concentrate on patients for that length of time can be tiring. The rewards are patient satisfaction - they are usually very happy and pleased that, from having a severe injury or deformity, they are able to live a relatively normal life.

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