Faculty Bibliography

STATEMENT OF PROBLEM/BACKGROUND:Understanding how maxillofacial prosthodontists are perceiving changes in head and neck care and the impact of advanced digital technologies on maxillofacial prosthodontics is important. However, no studies could be identified that specifically addressed these subjects. PURPOSE/OBJECTIVE:The purpose of this review of selected literature was to identify issues that guided the development of maxillofacial prosthodontics and the concerns that persist. The review also considered contemporary influences that will affect the future of maxillofacial prosthodontics. The conclusions of the review were used to interpret the results of the exploratory survey reported in Part II. MATERIAL AND METHODS/METHODS:The review of selected literature was related to the development of maxillofacial prosthodontics in North America between 1950 and 2018. Literature that was considered relevant to the purpose of the review was included. RESULTS:The review yielded 37 references of interest: 34 peer-reviewed publications, 1 guideline, 1 historical publication, and 1 website. Periods in the development of maxillofacial prosthodontics in North America were identified as formation, consolidation, and innovation. CONCLUSIONS:It was concluded that concerns in subspecialty programs and clinical practice had origins in the formation and consolidation periods. These persisting concerns extended into the innovation period. Contemporary influences in head and neck surgery will continue to affect the future of maxillofacial prosthodontics. Advanced digital technologies appeared to be central to driving change. Understanding the evolution of maxillofacial prosthodontics was an important first step in providing context when interpreting the results of a survey of maxillofacial prosthodontists reported as Part II of this work.

STATEMENT OF PROBLEM/BACKGROUND:Head and neck care has been transformed by the introduction of advanced digital technologies that will continue to be important change drivers for maxillofacial prosthodontics. Insight into these changes is important in answering the question of whether maxillofacial prosthodontics is appropriately prepared to contribute effectively to future multidisciplinary care of the head and neck. PURPOSE/OBJECTIVE:The purpose of this survey was to gain insight into the perception of changes experienced by maxillofacial prosthodontists in relation to clinical practice. The findings of this survey may assist the future development of the subspecialty. MATERIAL AND METHODS/METHODS:An exploratory cross-sectional survey was conducted by using a convenience sample of members of the American Academy of Maxillofacial Prosthetics. The survey considered 10 domains and 31 questions. Fully completed surveys (164) provided a 59% response. Descriptive statistics used percentage responses to reduce and characterize perceptions across respondents. RESULTS:Eighty-four percent of the respondents were from the United States. Results should be interpreted based on this cohort. Respondents reported a change in care delivered over the past 10 years (72%), with the most important causes of change attributed to surgery (60%) and advanced digital technologies (56%). Respondents perceived advanced digital technologies as being central to the future of maxillofacial prosthodontics (89%) and important in attracting younger colleagues (88%). Sixty-three percent believed training programs were not providing adequate education and training in the use of advanced digital technology. CONCLUSIONS:The perception of maxillofacial prosthodontists regarding changes taking place in care delivery was that the most important changes in the past 10 years were attributed to surgery and advanced digital technologies, that persisting pressures related to few institutional positions, that the subspecialty was poorly visible, that remuneration for care was inadequate and referring disciplines did not understand the subspecialty, that advanced digital technologies were considered central to the future of maxillofacial prosthodontics and important to attract younger colleagues to the subspecialty, that barriers to advanced digital technology use included funding for equipment acquisition, institutional funding support, and remuneration for their use in care delivery, and that maxillofacial prosthodontic programs were not providing adequate education and training in advanced digital technologies.

Since 2005, facial transplantation has emerged as a viable reconstructive option for the most severe defects not amenable to conventional reconstructive techniques, with promising aesthetic and functional outcomes to date. Key facial subunits and midface structures such as the eyelids, lips, and nose are now able to be successfully replaced rather than reconstructed, enabling adequate functional outcomes in even the most extensive defects. However, even in cases of severe facial disfigurement, the decision to proceed with transplantation versus autologous reconstruction remains a source of debate, with no current consensus regarding precise indications and inclusion/exclusion criteria. This report details the case of a candidate referred for face transplantation who ultimately underwent autologous facial reconstruction. Through this representative case, our objective is to clarify the criteria that make a patient a suitable face transplant candidate, as well as to demonstrate the outcomes achievable with a conventional autologous reconstruction, using a methodically planned, multistaged approach.

BACKGROUND:Facial transplantation (FT) is a challenging reconstructive endeavor that requires the expertise of a multidisciplinary team. The specific role of maxillofacial prosthodontists has not yet been reported in detail. METHODS:This review considers the contributions of prosthodontists throughout the FT process, from patient selection and dental evaluation to long-term dental rehabilitation of the transplant patient postoperatively. Moreover, considerations of dental management are evaluated. RESULTS:In the almost 40 FT reported in the literature, the most consistently documented contribution by prosthodontists is the fabrication of a donor mask to maintain donor integrity. Though infrequently reported, prosthodontists have the potential to plan and perform a variety of dental procedures and follow-up plans. CONCLUSIONS:When applicable, facial transplant teams are tasked with providing optimal stomatognathic function and dental occlusion to recipients with severe facial disfigurement. The maxillofacial prosthodontist's contribution is crucial to the long-term dental restoration of the edentulous facial transplant candidate, in addition to the fabrication of the donor mask which fulfills the team's ethical responsibilities. PRACTICAL IMPLICATIONS/CONCLUSIONS:Maxillofacial prosthodontists play a pivotal role in facial transplantation, particularly when jaw segments are intended for transplantation.

Background/Purpose: The reconstruction of the wide Tessier #4 cleft is classically limited by persistent lower lid ectropion/medical canthal disruption or the incorporation of unaesthetically located scars which violate the subunit border principle of facial reconstruction. We present a novel repair technique which: can be applied at infancy; does not require tissue expansion; restores stable lower eyelid and medial canthal position; and respects the subunit border principle of facial repair. Methods/Description: A neonate with a complete, wide, Tessier #4 facial cleft presents with an over 2/3rd lower eyelid loss. Presurgical tape therapy was applied to lengthen the lateral tissues transversely and vertically. A Tenzel flap extended to a Schrudde cervicofacial flap was planned to radically mobilize the lower eyelid to the medial canthus in a tension-free manner. A robust vascular supply was maintained to this large flap using a deep plane dissection. Results: Surgical repair was performed at 3 months of age. No tissue expansion was used. A Tenzel pattern flap was mobilized in the subcutaneous plane. This flap was raised in continuity with a Schrudde cervicofacial flap raised in the deep plane. Facial nerves were directly visualized and preserved during the operation. A conjunctival flap was raised from the floor of the orbit was used to reconstruct the posterior lamella of the lower eyelid. The Tenzel/Schrudde flap was rotated, without tension over the defect and to the nose/cheek junction. At the time of inset, there was redundant flap skin superiorly at the level of the lower eyelid and medially at the area of the medial canthus. This redundancy was incorporated into the reconstruction to prevent ectropion and medial canthus disruption. Suspensory sutures were applied to the infraorbital rim and pyriform aperture to prevent sagging of the flap. A Millard repair was used to reconstruct the lip at the level of the philtrum. The flap demonstrated 100% take despite radical mobilization. The final scar followed the philtral line, the nasal/cheek junction, the subcilliary line and the anterior auricular/retro auricular border. Lower eyelid and medial canthal position was stable after 6 months. Facial nerve function was preserved with this approach. Conclusions: A Tenzel/Schrudde deep-plane cervicofacial flap can be safely applied to infants with a wide Tessier #4 facial cleft. No tissue expansion is needed. This is the first repair technique which places final scars perfectly along the subunit borders of the face while preserving lower eyelid and medial canthal position, even in the patient with significant lower eyelid loss

BACKGROUND: Reconstruction of maxillary defects following tumor extirpation is challenging because of combined aesthetic and functional roles of the maxilla. One-stage reconstruction combining osseous free flaps with immediate osseointegrated implants are becoming the standard for mandibular defects, and have similar potential for maxillary reconstruction. METHODS: A woman with maxillary Ewing sarcoma successfully treated at age 9 with neoadjuvant chemotherapy, right hemimaxillectomy, and obturator prosthetic reconstruction presented for definitive reconstruction, complaining of poor obturator fit, and hypernasality. Her reconstruction was computer-simulated by a multidisciplinary team, consisting of left hemi-Lefort I advancement and right maxillary reconstruction with a free fibula flap with immediate osseointegrated implants and dental prosthesis. RESULTS: Full dental restoration, midface projection, and oral fistula corrections were achieved in 1 operative stage using this approach. CONCLUSIONS: This patient demonstrates a successful approach for maxillary reconstruction using computer-planned orthognathic surgery with free fibula reconstruction and immediate osseointegrated implants with dental prosthesis.

BACKGROUND: The application of aesthetic, craniofacial, and microsurgical principles in the execution of face transplantation may improve outcomes. Optimal soft-tissue face transplantation can be achieved by incorporating subunit facial skeletal replacement and subsequent tissue resuspension. The purpose of this study was to establish a reconstructive solution for a full face and scalp burn and to evaluate outcome precision and consistency. METHODS: Seven mock face transplants (14 cadavers) were completed in the span of 1 year. Components of the vascularized composite allograft included the eyelids, nose, lips, facial muscles, oral mucosa, total scalp, and ears; and skeletal subunits of the zygoma, nasal bone, and genial segment. Virtual surgical planning was used for osteotomy selection, and to evaluate postoperative precision of hard- and soft-tissue elements. RESULTS: Each transplant experience decreased each subsequent transplant surgical time. Prefabricated cutting guides facilitated a faster dissection of both donor and recipient tissue, requiring minimal alteration to the allograft for proper fixation of bony segments during inset. Regardless of donor-to-recipient size discrepancy, ample soft tissue was available to achieve tension-free allograft inset. Differences between virtual transplant simulation and posttransplant measurements were minimal or insignificant, supporting replicable and precise outcomes. CONCLUSIONS: This facial transplant model was designed to optimize reconstruction of extensive soft-tissue defects of the craniofacial region representative of electrical, thermal, and chemical burns, by incorporating skeletal subunits within the allograft. The implementation of aesthetic, craniofacial, and microsurgical principles and computer-assisted technology improves surgical precision, decreases operative time, and may optimize function.

BACKGROUND: Cadaveric face transplant models are routinely used for technical allograft design, perfusion assessment, and transplant simulation but are associated with substantial limitations. The purpose of this study was to describe the experience of implementing a translational donor research facial procurement and solid organ allograft recovery model. METHODS: Institutional review board approval was obtained, and a 49-year-old, brain-dead donor was identified for facial vascularized composite allograft research procurement. The family generously consented to donation of solid organs and the total face, eyelids, ears, scalp, and skeletal subunit allograft. RESULTS: The successful sequence of computed tomographic scanning, fabrication and postprocessing of patient-specific cutting guides, tracheostomy placement, preoperative fluorescent angiography, silicone mask facial impression, donor facial allograft recovery, postprocurement fluorescent angiography, and successful recovery of kidneys and liver occurred without any donor instability. Preservation of the bilateral external carotid arteries, facial arteries, occipital arteries, and bilateral thyrolinguofacial and internal jugular veins provided reliable and robust perfusion to the entirety of the allograft. Total time of facial procurement was 10 hours 57 minutes. CONCLUSIONS: Essential to clinical face transplant outcomes is the preparedness of the institution, multidisciplinary face transplant team, organ procurement organization, and solid organ transplant colleagues. A translational facial research procurement and solid organ recovery model serves as an educational experience to modify processes and address procedural, anatomical, and logistical concerns for institutions developing a clinical face transplantation program. This methodical approach best simulates the stressors and challenges that can be expected during clinical face transplantation. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.