All the below competencies and capabilities are built on the core skills of managing the acutely ill surgical/trauma patient. Acquiring these skills requires core training in medicine, surgery and dentistry including an on-call rota of appropriate frequency.
As mentioned earlier, these competencies and capabilities reflect OMFS training and practice across UEMS nations and are present in published national curricula, all of which are listed at www.omfsuems.eu . Were very specific definitions are present in a nation for example in Germany the Facharzt/Fachärztin für Mund-Kiefer-Gesichtschirurgie specifies ‘skin surgery on the entire integument’ the authors have ensured that this ETR is compatible with these competencies.
Management of the dying patient – is able to manage the transition from life to death including palliation of symptoms, certification of death and discussion of resuscitation status/organ donation.
Acquisition and processing of investigations - basic laboratory procedures and investigations across all OMFS pathologies including OMFS laboratory (impressions, 3D planning), blood and tissue samples with appropriate taking/handling of samples and interpretation of results, tumour markers, immunology investigations, model surgery and consent.
Working within the relevant legislation – not just medical negligence but also consent, social welfare, equality diversity and inclusion, prescription, radiation protection, use of lasers and photodynamic therapy etc.
Accurate examination and medical records: photography, 3D surface scanning, clinical and computer measurement, nasendoscopy, sialendoscopy, examination adjuncts.
Key Competences in Oral and Maxillofacial Surgery
Holistic management of the OMFS Patient including medical co-morbidities
Building on core surgical, core medical and core dental skills detailed in the core curriculum.
Adjunctive Para-surgical Competencies
Local, locoregional anaesthesia; intravenous conscious sedation (pharmacology, techniques, complications). Management of pain and anxiety including non-medical management of chronic pain, analgesics, co-analgesic medicines and sedation.
Competencies in the management of Head Face and Neck (OMFS) emergencies
Emergency airway - including front of neck access under LA and GA. Cricothyroidotomy, tracheostomy (open, percutaneous) in adult and child, sub-mental intubation.
Bleeding: surgical and medical management of bleeding from facial/neck trauma including epistaxis associated with mid-face fractures (with reduction and immobilisation of fractures before nasal packing)., post-surgical bleeding (including post-extraction), non-traumatic epistaxis (nasal packing, cauterisation), medical conditions associated with bleeding, carotid blow-out, catastrophic bleeding from ballistic/blast injuries, within a multidisciplinary team.
Trauma - Resuscitation and early management of the patient who has sustained thoracic, head, spinal, abdominal and/or limb injury according or European Trauma Course or ATLS® or APLS guidelines including emergency cricothyroidotomy, tracheostomy and insertion of chest drain. Penetrating and ballistic injuries of the face and neck. Acute bleeding including neck access, midface stabilisation, packing. Dental trauma/avulsion of teeth. Neurovascular tissue repair. Repair of nasolacrimal system.
Eye-sight threatening injuries: Retrobulbar haemorrhage/orbital compartment syndrome (lateral canthotomy, medical management), acute surgery for white-eye blowout, lateral canthopexy, orbital nerve decompression within a multidisciplinary team.
Sepsis – able to apply a systematic, prioritised method of managing the septic patient following national/international guidelines including resuscitation and early management of the septic patient, surgical draining of pus and removal of the causative tooth. Cranio-maxillo-facial infections involving bone and soft tissues in the facial head and neck area including management of acute odontogenic infections and deep infections of the face and neck including life-threatening swelling requiring extra oral drainage and extensive resection (necrotising fasciitis) including surgical removal of the associated tooth.
Critically ill surgical patient - in discussion with the critical care team, to the management plan of a patient receiving critical care and management of perioperative emergencies e.g. thrombo-embolic disease, diabetic crises, fluid balance, decompensation. Carotid blow-out, free flap compromise and other acute post-operative conditions.
Requesting, interpretation (including CT, MRI, PET, and radio isotope imaging) and, where appropriate elements of interventional imaging/procedures specific to oral and maxillofacial surgeon. This includes advanced clinical examination with task specific instruments e.g. endoscopy, ultrasonography, sialography, sialendoscopy, doppler ultrasonography (including implantable probes), dental radiography (intra-oral, extra-oral), Cone Beam CT (CBCT), C-arm CT, CT including imaging in theatre.
An important part of the clinical use of modern 3D imaging is integration with treatment planning, custom implants, surgical guides, and stereotactic guided procedures. These competencies are especially relevant in deformity and cancer surgery.
Where additional training is required to prescribe, perform or interpret investigative procedures e.g. radiation protection regulations, cone-beam CT, ultrasound guided biopsy or sentinel node biopsy, these should be part of the OMFS training programme.
Leadership and Management Competencies
OMFS trainees should be trained to be leaders within their department, and also in roles which extend beyond this narrow interpretation of clinical practice. For example OMFS surgeons play a key role in the bridge between dental and medical imaging of the face and surrounding tissues that they often undertake important leadership roles in this area of practice. Within multi-disciplinary clinics, OMFS trainees should acquire competencies in the management of their patient and the team. Teaching and research roles, from tutor to professor, include competencies in the breadth and depth of leadership and management. Competencies within the administration of education and health care locally, regionally, nationally and internationally are essential elements of training.
Oral Surgery, Oral Medicine, Oral Pathology and Oral Diagnosis Competencies
Oral manifestations of systemic disease and their managements including multidisciplinary care.
Surgical removal of teeth including wisdom teeth and other extractions including palatal teeth/supernumeraries.
Exposure of unerupted teeth including bonding of brackets/gold-chain.
Cyst biopsy, fenestration, enucleation and treatment with cryotherapy or chemical agents (Carnoy’s). Periapical surgery/surgical endodontics.
Surgical orthodontics and transplantation of teeth.
Management of oro-antral and oro-nasal communication/fistulae: including joint management with ORL (closure of communication/fistula combined with Functional Endoscopic Sinus Surgery – FESS).
Diagnosis and management of facial palsy including multidisciplinary care.
Competencies in salivary gland surgery
Management of inflammatory and neoplastic (benign and malignant) diseases of the major and minor salivary glands including:
Minimally invasive salivary surgery including management of sialoliths with scopes (rigid and flexibe), lithotripsy, lasers and transoral retrieval, biopsy of gland,
Management of ranulas including minimally invasive procedures, resection of plunging ranulas with removal of the involved sub-lingual gland.
Submandibular gland surgery including removal using open and endoscopically assisted techniques, trans-oral removal of sialoliths.
Parotid Surgery including extra-capsular resection of tumours, Partial parotidectomy, total parotidectomy, radical parotidectomy
Head, Face and Neck Trauma Competencies
Management of cranio-maxillo-facial trauma (bone, teeth and soft tissues), both acute injuries and management of post-traumatic/secondary deformity of bone, teeth and soft tissues.
Comprehensive management fractures and dental injuries: of single bones complex pan-facial fractures (including removal of teeth in the line of fractures at time of surgery) using indirect fixation (intermaxillary wires/elastics), external fixation, and plating.
Computer assisted planning of cases, custom implants, endoscopically assisted surgery, minimally invasive techniques.
Surgical access to repair fractures facial fractures: mandible (including condyle), maxilla, zygoma, orbit, naso-orbito-ethmoid, frontal bones, orbital floor/medial wall including coronal flaps, face-lift approaches, minimally invasive and endoscopically assisted techniques.
Management of facial soft tissue wounds including lacerations, human bites, animal bites, avulsive injuries, knife/glass wounds, blast and ballistic trauma. Repair and replacement including reconstruction and implant borne/adhesive prosthetic replacement e.g. dento-alveolar tissue, nose, maxilla, orbit/eye, ear.
Combined Trauma Surgery: trauma does not respect specialty or anatomical boundaries. Best patient care will often involve working with other specialties in complex poly-trauma. Working within this team is a key competency and capability for an OMFS specialist and the presence of OMFS specialists is a requirement in Level 1 and Level 2 Major Trauma Centres.
Management of post-traumatic deformity: whilst this may be relatively simple such as scar revision surgery (Z-Plasty, W-Plasty and Geometric Broken Line Closure) .it may include all hard and soft tissue techniques listed under facial deformity/aesthetic surgery and facial reconstruction surgery.
Competencies in skin surgery/surgical dermatology
Surgery is an element in the diagnosis and management of skin conditions. The role of colleagues in dermatology/venereology and the whole multidisciplinary team (especially in cancer) can be key. Understanding of the role of UV-light, skin types and classifications, diagnosis of pigmented lesions and understanding of precancerous lesions is essential. In some nations, for example Germany, OMFS is the only specialty recognised to operate on the skin of the ‘whole body integument’. In this context, the ETR must reflect this scope of practice.
Skin surgery including biopsy or excision of benign and malignant lesions (malignancy is usually in managed in a multi-disciplinary team). Primary closure, skin graft – full thickness and split thickness, alloplastic dermis, and local/regional flap closure and free tissue transfer. Sentinel node technique in melanoma and aggressive cancer. Parotid surgery for lymph node metastasis. Skin surgery would include curettage/electrocautery & photodynamic therapy, topical 5FU and other ablative techniques.
Competencies in Facial Aesthetic and Functional Surgery
The anatomical focus of OMFS is the face, and so key competencies include the repair, restoration and improvement the shape, function and aesthetics of the head and neck region through surgical and non-surgical interventions. This includes rehabilitation of the aging face including dental rehabilitation (see pre-prosthetic surgery/implants).
Facial soft tissue surgery - Aesthetic/cosmetic/head neck and facial surgery. Rehabilitation of the ageing face-and/or neck-lift, SMAS dissection, foreheadplasty, brow lifting, otoplasty, blepharoplasty, genioplasty, ablative, augmentative and paralysing treatment of facial wrinkles and scars, Filler/fat transfer, facial implants (chin/malar/other), paralysing treatment of facial wrinkles, muscular hypertrophy and facial nerve paresis. Rhinophyma management and operative techniques, facial resurfacing (chemical peel, laser resurfacing, dermabrasion), cryotherapy and other adjuncts, liposuction and facial prosthetics.
Facial orthopaedic surgery including gender reassignment and surgery for sleep apnoea – Clinical and computer-based planning of the management of facial bone abnormalities including 3D computer planning, printed wafers, surgical guides and pre-formed plated for mandibular, maxillary osteotomies including segmental and genioplasty. Surgical and non-surgical management of obstructive sleep apnoea within a multi-disciplinary team. Surgery of the nose and nasal complex for trauma, post-trauma and malformation. Ear surgery: including harvesting of cartilaginous grafts, reconstructive surgery due to trauma, agenesis or malformation. Zygomatic and orbital osteotomies. Use of distraction in alveolus, mandible, maxilla (off the shelf and custom made; internal and external. Use of lasers for incision, treatment of vascular lesions/skin pigmentation and re-surfacing.
Combined soft and hard tissues surgery: any and all combinations of the above including nasal surgery (open, closed, augmentation/grafting and managing cleft deformity). Gender reassignment surgery techniques are not unique to this area of practice but would usually be part of multidisciplinary care. Similarly the range of medical and surgical interventions (including bi-maxillary advancement) for sleep disorders is usually multidisciplinary with sleep physicians and others. Facial reanimation surgery across the whole reanimation ladder from gold weight, static sling, through muscle sling, neural transfer, functional (neuro-muscular) local flap and free flap.
Surgery for mouth, jaw, face and neck tumours
Surgery is only an element of the care for head face and neck tumours (benign and malignant) of skin, bone/connective tissue and mucosa. The specialist must have an understanding of aetiology, , carcinogenesis, molecular biology, genetic and epigenetics, immunobiology, epidemiology, biostatistics, chemotherapy, radiotherapy, virology (esp HPV) and the different staging systems (according to the underlying disease) of cancer. As understanding progresses, surgery for malignant disease may become rarer but it remains a key element of the treatment of oral and facial primary and secondary cancer.
Management of benign lesions causing functional or aesthetic problems including ectopic teeth and dental tissue, benign tumours, cysts, vascular malformations (haemangioma, lymphangioma, AV malformation) and other congenital/developmental abnormalities including thyroglossal and branchial cysts) and benign neck tumours (including paraganglioma, haemangioma, schwannoma).
Oro-facial resection malignant disease of hard and soft tissue of oropharynx, maxilla, mandible, tongue, face, salivary glands and neck. Composite resections (rim/segment of mandible, partial complete maxillectomy), orbitotomy and exenteration of orbit, pull-through procedure, combined surgery, trans-oral laser, robotic surgery, mandibulotomy, mandibular/maxillary swing, midfacial degloving and other adjunctive techniques.
Management of regional lymph nodes with elective neck dissection, selective neck dissection, radical neck dissection, and sentinel node biopsy. Use of robotic surgery and other surgical adjuncts including 3D planning, resection guides, frozen section, real-time genetic analysis.
Management of the unknown primary within a multidisciplinary team
Palliative Care: in co-operation with the multi-disciplinary team including photodynamic therapy, electro-surgery, cryotherapy and interferential therapy for lesions which are beyond curative intent. Wholistic management of the patient and their family.
Pain management: Therapeutic procedures for neuropathic pain where indicated including cryotherapy other ablative techniques.
Facial Reconstruction and Rehabilitation
Regional reconstructive surgery including harvesting of hard and soft tissue grafts, loco-regional flaps, microsurgery, tissue expansion. Craniofacial prosthetics including implant borne prosthesis, harvesting and use of non-vascularised bone or cartilage, Local skin/muscle flap, free tissue transfer (raising, insetting and anastomosing flap), raising and in-setting pedicled flaps.
Cleft and Craniofacial Surgery
Management of patients with cleft lip/palate and craniofacial abnormalities is multidisciplinary including geneticists, ORL, plastic surgery, neurosurgery as well as professions allied to medicine. Surgical competencies in treating congenital/developmental abnormalities of the head, face and mouth including cleft lip and palate surgery, pharynx surgery and alveolar bone graft are only an element of the competencies required to practice in these areas.
Cleft lip and palate: lip and palate surgery, pharynx surgery and alveolar bone graft, management of complications of primary surgery including nasal surgery, orthognathic surgery, use of distraction, rib grafts bone grafts, tongue flaps, free flaps and the whole ranges of facial aesthetic surgery within the multidisciplinary team.
Paediatric Craniofacial surgery. Surgical corrections of syndromes of the head, face and neck including fronto-orbital advancement Le Fort II / III / Monobloc Posterior distraction and cranioplasty. Management of macroglossia.
Adult Craniofacial Surgery: for trauma and tumour. Trans-facial/trans-oral access for surgery of anterior skull base including (inc. osteoplastic flap, duraplasty and endoscopic) multi-disciplinary management.
Temporomandibular Joint and Facial Pain
Surgical and non-surgical management of temporomandibular joint diseases and disorders including arthrocentesis, arthroscopy and open TMJ procedures.
Alloplastic and prosthetic replacement of the TMJ including rib-graft, stock TMJ prosthesis and custom made including 3-D planning and use of surgical guides.
Facial Pain - The accurate diagnosis and management of facial pain of all causes including multidisciplinary care of atypical facial pain and other similar complex pain/psychosomatic disorders.
Competencies in Implants / Pre-prosthetic Surgery
Pre-prosthetic surgery including hard and soft tissue grafting and implantology with immediate and delayed osseo-integrated implant placement (intra and extra-oral). 2nd stage or revision surgery for implants.
Learning Agreements (Knowledge, Core Competencies and Index Procedures).
The Appendix 1 lists the key elements of knowledge and Appendix 2 the logbook of procedures that trainees should know/understand/have experience at completion of training. The knowledge base extends into interface areas stressing awareness of other specialties and when referral or joint working is in the best interests of patients. The specific procedures which the trainees will be able to perform independently will vary across training programmes and nations. To help trainees pace their training, an outline of these ‘index procedures should be available at the start of the training programme. Trainees should have been directly involved in the pre- and post- operative management of their patients and should have a detailed understanding of the preoperative diagnostic investigations. An example of an index procedures which is common across all nations is a tracheotomy as this may be needed as an emergent procedure in airway threatening facial trauma or acute cervicofacial space infections.
If the minimum number of index procedures is not met, other evidence for example procedure-based assessments or a comparable key procedure in the same area of practice may be sufficient to demonstrate competence.
The levels of skill required to attain competence (as determined by the training supervising body as well as the national regulations) have been refined by adding the Entrustable Professional Activity or EPA. EPA is a fifth level added to the existing classical four levels of competence: the key concept is Entrustment. The trainee has not only reached the required level of competence, they are trusted to perform a procedure by their tutor/trainer/supervisor. The use of EPAs reflects the establishment of a competency-based training, in which a flexible length of training is possible and where the educational outcomes prevail.
Excellence and Mastery
Training programmes focus on competence but it is important that training programmes recognise the potential for excellent and mastery. Often this requires additional focus on areas of sub-specialty practice. This should be encouraged but not at the expense of core skills/knowledge.
Levels of Skill
- Has observed – the trainee acts as an ‘Assistant’. From complete novice through to being a competent assistant. At end of level 1 the trainee:
- Has adequate knowledge of the steps through direct observation.
- Demonstrates that they can handle the apparatus relevant to the procedure appropriately and safely.
- Can perform some parts of the procedure with reasonable fluency
- Can do with assistance - a trainee is able to carry out the procedure ‘Directly Supervised’. From being able to carry out parts of the procedure under direct supervision, through to being able to complete the whole procedure under lesser degrees of direct supervision (e.g. trainer immediately available). At the end of level 2 the trainee
- Knows all the steps - and the reasons that lie behind the methodology.
- Can carry out a straightforward procedure fluently from start to finish.
- Knows and demonstrates when to call for assistance/advice from the supervisor (knows personal limitations).
- Can do the whole procedure but may need assistance – a trainee is able to do the procedure ‘indirectly supervised’. From being able to carry out the whole procedure under direct supervision (trainer immediately available) through to being able to carry out the whole procedure without direct supervision i.e. trainer available but not in direct contact with the trainee. At the end of level 3 the trainee:
- Can adapt to well-known variations in the procedure encountered, without direct input from the trainer.
- Recognises and makes a correct assessment of common problems that are encountered.
- Is able to deal with most of the common problems.
- Knows and demonstrates when they needs help.
- Requires advice rather than help that requires the trainer to scrub.
- Competent to do without assistance, including complications. The trainee can deal with the majority of procedures, problems and complications, but may need occasional help or advice.
- Can be trusted to carry out the procedure, independently, without assistance or need for advice. This concept would constitute one Entrustable Professional Activity (EPA). An EPA is ‘a critical part of professional work that can be identified as a unit to be entrusted to a trainee once sufficient competence has been reached’. This would indicate whether one could trust the individual to perform the job and not whether he is just competent to do it. At the end of level 5 the trainee:
- Can deal with straightforward and difficult cases to a satisfactory level and without the requirement for external input to the level at which one would expect a consultant surgeon to function.
- Is capable of instructing and supervising trainees.
- Has observed.
- Can do with assistance.
- Can do whole but may need assistance.
- Competent to do without assistance, including complications, but may need advice or help.
- Can be trusted to carry out the procedure, independently, without assistance or need for advice (EPA).
Though the above detailed classification of Competence Levels is very useful during the process of (formative) training, when it comes to deciding when an applicant is eligible to sit an eventual Specialist Exit examination, it is the evaluation of the EPAs which is essential. In this sense, the Eligibility Assessment Process is really the first part of the Examination and that explains the suggestion that the ‘5th level of Technical Skills competence’ should be included in a standardised Logbook Template for all trainees.
Definition: NTS involve the cognitive and social skills that are necessary for safe and effective health care. This must be a formal part of the Syllabus/Curriculum.
- Decision making
- Situation awareness
Professionalism. Ethics and Medico-legal
- Respect and compassion towards the sick
- Respect towards colleagues and junior staff
- Abide by the values of honesty, confidentiality and altruism
- Maintain competence throughout our careers
- Improve care by evaluating its processes and outcomes
- Participate in educational programmes
- Provide care irrespective of age, gender, race, disability, religion, social or financial status
- Deliver best quality care in a compassionate and caring way
- Caring for colleagues in difficulty
- Patient confidentiality
- Autonomy, informed consent & competence
- Identification of presentations which may be the result of abuse and/or violence
- End-of-life/palliative care
- Forensic Issues
- Global health
 Bundesärztekammer (Arbeitsgemeinschaft der deutschen Ärztekammern page 220 https://www.bundesaerztekammer.de/fileadmin/user_upload/downloads/pdf-Ordner/Weiterbildung/20210630_MWBO_2018.pdf