- Email: [email protected]
Harvard MD Oral and Maxillofacial Surgery Program
FROM THE TEACHING CENTERS
Massachusetts General Hospital/Harvard MD Oral and Maxillofacial Surgery Program Leonard B. Kaban, DMD, MD,* and Walter C. Guralnick, DMD†
FIGURE 1. Main entrance to Massachusetts General Hospital, 2004: center, White Building; left foreground, old clinics building; left background, Ellison and Blake Towers; and right, Wang Ambulatory Care Center.
The present Oral and Maxillofacial Surgery Service at Massachusetts General Hospital (MGH) (Fig 1). began in 1867 when the Harvard Dental School, the first university-affiliated dental school in the country, was founded. Physicians at Harvard and MGH identified a need for “doctors of dental medicine” analogous to “doctors of medicine.” The new Received from Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA *Walter C. Guralnick Professor and Chairman. † Professor of Oral and Maxillofacial Surgery, Emeritus. Address correspondence and reprint requests to Dr Kaban: Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. [email protected] 0278-2391/05/6308-0002$30.00/0 doi:10.1016/j.joms.2005.04.033
FIGURE 2. Department of Oral and Maxillofacial Surgery, June 2004. First row: Matthew Jacobsen, Jose Ramirez, Basel Sharaf, Leonard Kaban, Tuan Bui, Mark Nissenbaum, Jeff Hammoudeh; second row: Brad Williams, Jeffry Shaefer, Nanlin Chiang, An-Louise Johnson, Mailikai Abulikemu, Arnulf Baumann; third row: Walter Guralnick, Carol Lorente, Maria Troulis, Bruce Donoff, Meredith August, Thomas Dodson; fourth row: Thomas Albert, Fardad Tayebaty, Leslie Halpern, Edward Seldin, Sung-Kiang Chuang.
dental school occupied a building on Grove Street, adjacent to the MGH, recently vacated by the Harvard Medical School. It was within this building that the Dental Infirmary of the MGH, the parent of the present Department of Oral and Maxillofacial Surgery, was established. Six dentists and a dental surgeon were appointed to the staff, and it is noteworthy that they treated 4,000 patients a year. In 1909, the Dental School moved to Longwood Avenue, its current location adjacent to the Medical School. An Oral Surgery clinic within the hospital was then established. Leroy M.S. Miner, DMD, MD, who subsequently became dean of the Dental School and Professor of Oral Surgery, was appointed chief of the service in 1924 and remained in that capacity until 1943. Dr Daniel Holland was Miner’s most prominent trainee. 1069
He became Chairman of Oral Surgery at Tufts, and he was president of the American Board of Oral Surgery from 1960 to 1961. In 1942, the school was reorganized and became the Harvard School of Dental Medicine. Dr Kurt Thoma, who had been the Charles Brackett Professor of Oral Pathology, was appointed Professor of Oral Surgery and, in 1943, became chief of the MGH Oral Surgical Service. Thoma’s international reputation brought considerable prestige and recognition to the department. He also established the department’s geographic orientation in the hospital rather than in the dental school. It is important to note that, before Thoma, oral surgeons were not allowed to operate in the hospital’s operating rooms. He broke down those barriers and established a strong and respected service that he headed for 6 years.
1070 Thoma was succeeded in 1949 by David Weisberger, DMD, MD, a 1930 graduate of Harvard Dental School who subsequently obtained his MD degree from Yale University under a Sterling Fellowship. Dr Weisberger’s research interest and expertise were in oral medicine. During his tenure as chief of the service, the name of the department was changed to Oral Medicine even as it continued to accept 1 resident per year for training in oral surgery. In 1965, the Commission on Dental Accreditation (CODA), upon Dr. Weisberger’s petition, allowed the program to accept 2 residents each year. In 1967, upon Dr Weisberger’s death, Dr Walter Guralnick, who had been on the faculty of the Harvard School of Dental Medicine and the MGH since 1950, became department chairman and chief of the MGH service. Dr. Guralnick remained chief until 1983. During his tenure, the hospital agreed to restore the name to Department of Oral Surgery, a descriptor that subsequently changed, in 1979, to oral and maxillofacial surgery (OMFS) in recognition of the broadened scope of the specialty. A full-time faculty of qualified oral surgical specialists was appointed along with part-time oral surgeons to provide both clinical care and teaching. A research program was established and a unique predoctoral teaching experience was initiated. Harvard dental students were all assigned to MGH for a 1-month clerkship in OMFS. This was an undergraduate dental school experience that was unique and continues to be a highlight of the Harvard School of Dental Medicine’s curriculum. To expand the educational content of the residency, 3-month rotations in anesthesia, medicine, and general surgery were established, as well as exchange programs with leading European OMFS centers. A major innovation in oral surgical education was introduced in 1971.
FROM THE TEACHING CENTERS
With the unanimous approval of the Harvard Medical School faculty, a combined 5-year Oral Surgery/MD program was begun. It was originally limited to graduates of the Harvard School of Dental Medicine and ran simultaneously with the traditional 3-year residency. The MD program was predicated upon the conviction that oral surgeons needed more medical knowledge and the same basic general surgical background as all other surgical specialties. Acquiring the MD degree fulfilled the educational requirements and allowed OMFS trainees to serve as full-fledged, licensed general surgical residents for 18 months. The first graduates of the program were Steven Roser (now professor and chairman of OMFS at Emory University), R. Bruce Donoff (dean, Harvard School of Dental Medicine), Leonard Kaban (Walter C. Guralnick Professor, department chair, and chief of OMFS at MGH), and Edward Seldin (associate professor of OMFS at MGH). The 2-track program was eliminated during Dr Donoff’s tenure as chief of the service and further refined by the current chief, Dr Leonard Kaban, so that all residents are now in a 6-year combined degree program. Another significant improvement in the program occurred in 1972, when an affiliation with the Peter Bent Brigham and Children’s Hospitals was established. Dr Kaban became director of OMFS at the Brigham and Children’s Hospitals, and all chief residents rotated through these hospitals for 6 months. OMFS was part of the Division of Plastic and Oral Surgery, headed by Dr Joseph Murray. The affiliation added an important dimension to the training program, providing experience in pediatric and craniofacial surgery performed infrequently at MGH. It also provided a model of collaboration between plastic surgery and OMFS. In 1983, Dr Donoff succeeded Dr Guralnick as chief of the service and chairman of the department at Har-
vard School of Dental Medicine. During his tenure as chief (1983– 1993), Dr Donoff was granted approval to have all MGH OMFS residents accepted into the doubledegree track, thereby eliminating the 2-tiered program. In 1982, the outpatient unit moved into new and expanded quarters in the Wang Ambulatory Care Center. John P.W. Kelly, DMD, MD, was appointed director of the OMFS Outpatient Unit and the Residency Program. Dr Kelly is a graduate of the MGH OMFS Program and subsequently became a leading educator in OMFS. He was president of the American Board of OMFS from 1995 to 1996. Dr Donoff recognized a longstanding need for a dental facility to care for hospital inpatients as well as hospital personnel. After a nationwide search for a dentist to head such a unit, Agnes Lau, DMD, was appointed and the dental program was established as a division of the OMFS Service. In addition, the MGH Dental Unit became part of the Harvard-wide General Practice Dentistry Residency Program based at Brigham and Women’s Hospital. Under Dr Donoff, the research program and clinical activity were expanded. Dr Charles Bertolami, a graduate of the residency program in 1980 and a recipient of a DMedSci degree from Harvard, successfully worked to establish a dedicated Department of OMFS Laboratory at MGH. Subsequently, Dr Bertolami left MGH to become professor and chairman of OMFS at UCLA and then dean of the Dental School at the University of California San Francisco. The laboratory remains in the department and is now the home of the Department of OMFS Skeletal Biology Research Center. To accommodate the increasing complexity and volume of clinical activity, Dr Donoff was granted permission to increase the number of first-year residents from 2 to 3 in 1990. In 1992, Dr Donoff was appointed dean of the Harvard School of Dental Medicine. An ad hoc com-
1071
KABAN AND GURALNICK
mittee was subsequently formed to search for his replacement as chief of service and chairman. In 1993, the Walter C. Guralnick Chair in Oral and Maxillofacial Surgery was established at MGH. In 1994, Dr Kaban was selected to become the Walter C. Guralnick Professor of Oral and Maxillofacial Surgery, department chairman, and chief of the Oral and Maxillofacial Surgery Service at MGH. The Kaban tenure demonstrates yet another expansion of the specialty of OMFS at MGH and mirrors the changes of the specialty nationwide. Dr Kaban’s particular research and clinical interests are in pediatric and craniomaxillofacial surgery. His years at Boston’s Children’s Hospital and the University of California San Francisco provided him with unique knowledge and experience in these areas. In addition, his eclectic clinical and research interests encompass the current broadened parameters of the specialty. In continuation of his early work in skeletal biology, Dr Kaban obtained MGH support to establish the Department of OMFS Skeletal Biology Research Center in 1996. This is a multidisciplinary center, within the department, with participation by the Departments of Surgery and Orthopaedic Surgery. Julie Glowacki, PhD, professor of OMFS and orthopaedic surgery and a longtime collaborator with Dr Kaban, was appointed the first director of the center. This center, currently under the direction of Dr Maria Troulis, focuses on developmental skeletal biology with projects in fetal bone healing, the biology of distraction osteogenesis, tissue engineering of bone and teeth, the effects of inflammation on skeletal wound healing, and minimally invasive surgical techniques. In 1996, with support from Synthes Corporation (Paoli, PA) and the AO-ASIF Foundation (Berne, Switzerland), a Pediatric OMFS Clinical and Research Fellowship was established in the department. Dr Troulis, a graduate of McGill Univer-
sity, Montreal, was the first 2-year Synthes Fellow. She has remained on the faculty of the department and has been instrumental in the development of the research program in distraction osteogenesis, tissue engineering, and minimally invasive surgery. With expansion of the clinical and research programs, Dr Kaban began the recruitment process for a new residency director to provide structure and closer supervision for the trainees. Dr David Perrott was appointed to this position and remained for 2 years. Then, in 1998, Dr Thomas Dodson, DMD, MPH, was appointed unit chief and program director after a nationwide search. Dr Dodson came to MGH from his immediate past position as residency program director at Emory University. Dr Dodson, who practices the full scope of OMFS, is a recognized expert in the field of evidence-based surgical practice, a health care discipline of currently increasing importance. Dr Bonnie Padwa, who is a graduate of Harvard School of Dental Medicine, Harvard Medical School, and the MGH OMFS Program, was recruited to remain on the faculty in 1995, and she is the director of the Longwood Area component of the Residency Program. Dr Padwa is a member of the Craniofacial Center at Children’s Hospital and a close collaborator of John Mulliken, the director. They provide our residents with a unique craniofacial experience. The combination of the Children’s Hospital and MGH Pediatric OMFS experience is unique for a training program of our specialty. This program continues to demonstrate the benefit of collaboration. In the early 1990s, the Harvard School of Dental Medicine class size increased from 20 to 35, necessitating an expansion of the predoctoral program. In 1999, Dr Thomas Flynn was recruited as the director of predoctoral education at Harvard. He has expanded the program on-site at the dental school to accommodate changes in both curriculum and
class size. Dr Meredith August, a 1987 graduate of the MGH OMFS Program, runs the predoctoral MGH externship program for Harvard and visiting students. A major focus of the department has been the development of minimally invasive technologies to improve patient care. These include distraction osteogenesis, tissue engineering, and endoscopic techniques for exposure of the craniomaxillofacial skeleton and treatment of salivary gland disease. Dr Troulis has directed this program, and beginning in 2001, the department has offered a continuing education course: Minimally Invasive Approaches to Mandibular Ramus/Condyle Unit Reconstruction and Salivary Disease. With MGH and international faculty, this course has enrolled OMFS faculty, program and department chairs, and private practitioners to learn these new techniques. Dr Troulis heads an AAOMS task force to develop recommendations regarding the impact of such novel technologies on OMFS training and practice. Under Dr Kaban’s leadership, to improve access to care for all MGH patients and to improve the educational experience of OMFS and general dentistry residents, the Dental Service was expanded to include all dental specialties. A new, dedicated outpatient dental facility was constructed on the MGH campus, and a program for operating room dental rehabilitation of handicapped patients was begun. The MGH Dental Group has grown to include 6 general dentists and specialists in periodontology, prosthodontics, endodontics, pediatric dentistry, and orthodontics. The MGH Oral and Maxillofacial Service is particularly noteworthy for its eclectic scope— teaching, research, and a broad scope of practice from dentoalveolar surgery to all aspects of craniomaxillofacial and tumor surgery. A profile of the service is best found by browsing the
1072
DISTRACTION OSTEOGENESIS FOR CHILDREN WITH MICROGNATHIA
Web site (www.massgeneral.org/ newomfs/) (Fig 2). The MGH program accepts 3 residents each year who are graduates of dental schools throughout the country. The present group of residents includes graduates of the University of Pennsylvania, University of California San Francisco, University of California Los Angeles, University of Connecticut, McGill University, Temple University, Tufts University, Ohio State University, and Harvard, among
others. Acceptance as a resident in OMFS automatically provides advanced standing admission to the Harvard Medical School after the first year of internship. Perhaps the greatest strength of any OMFS department is its faculty. The MGH program has 20 full-time faculty at MGH and affiliated institutions: Brigham and Women’s, Children’s Hospital, Beth Israel Deaconess Medical Center, and Harvard School of Dental Medicine. There also are
26 part-time faculty. This dedicated group has had a significant impact on our students and trainees for generations. The MGH program in OMFS has a strong commitment to diversity, which is reflected in its significant number of women and minorities who are its trainees and staff. It also continues to demonstrate its commitment to continuing requirement and expansion of the art and science of OMFS through basic and clinical research.
Mandibular Advancement by Distraction Osteogenesis for Tracheostomy-Dependent Children With Severe Micrognathia Derek M. Steinbacher, DMD, MD,* Leonard B. Kaban, DMD, MD,† and Maria J. Troulis, DDS, MSc‡ Purpose: The purpose of this study was to evaluate mandibular lengthening by distraction osteogenesis
(DO) to achieve decannulation of micrognathic children with “permanent” tracheostomies. Patients and Methods: Using a retrospective chart review, patients were included who had 1) airway compromise/tracheostomy, 2) micrognathia, 3) polysomnography-documented obstructive apnea, and 4) mandibular advancement using DO. Excluded were 1) adults, 2) neonates without tracheostomy, and 3) patients with central apnea. Patient age, past medical history, age at tracheostomy, and distraction protocol were documented. Oxygen saturation, posterior airway space (in millimeters), and sella-nasion-B point (SNB) angle were recorded. The distraction protocol consisted of a latency of 48 hours and a rate of 1 mm/day. Results: There were 5 children, aged 2 to 14 years, who received a tracheostomy between ages 2 and 36 months for airway obstruction. All patients underwent bilateral mandibular distraction using semiburied, unidirectional devices. The average latency was 58 hours, the rate was 1 mm/day, the duration of fixation was 40 to 60 days, and the magnitude of advancement was 23 mm. Healing was evaluated by clinical, radiologic, and ultrasound examinations. No complications were experienced. Mean follow-up was 3.2 years. Postdistraction sleep studies demonstrated no obstructive apneic events and a mean oxygen saturation of 98% (preoperative, 76%, P ⬍ .005). Cephalometric values improved: posterior airway space 4 to 14 mm; SNB 66° to 72° (P ⬍ .005 for both variables). Four of the 5 patients have been successfully decannulated to date. Conclusions: The results of this preliminary study indicate that mandibular advancement by DO is a potentially viable treatment option for tracheostomy-dependent children with upper airway obstruction secondary to micrognathia. © 2005 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 63:1072-1079, 2005
Massachusetts General Hospital/Harvard MD Oral and Maxillofacial Surgery Program Leonard B. Kaban, DMD, MD,* and Walter C. Guralnick, DMD†
FIGURE 1. Main entrance to Massachusetts General Hospital, 2004: center, White Building; left foreground, old clinics building; left background, Ellison and Blake Towers; and right, Wang Ambulatory Care Center.
The present Oral and Maxillofacial Surgery Service at Massachusetts General Hospital (MGH) (Fig 1). began in 1867 when the Harvard Dental School, the first university-affiliated dental school in the country, was founded. Physicians at Harvard and MGH identified a need for “doctors of dental medicine” analogous to “doctors of medicine.” The new Received from Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, Boston, MA *Walter C. Guralnick Professor and Chairman. † Professor of Oral and Maxillofacial Surgery, Emeritus. Address correspondence and reprint requests to Dr Kaban: Department of Oral and Maxillofacial Surgery, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. [email protected] 0278-2391/05/6308-0002$30.00/0 doi:10.1016/j.joms.2005.04.033
FIGURE 2. Department of Oral and Maxillofacial Surgery, June 2004. First row: Matthew Jacobsen, Jose Ramirez, Basel Sharaf, Leonard Kaban, Tuan Bui, Mark Nissenbaum, Jeff Hammoudeh; second row: Brad Williams, Jeffry Shaefer, Nanlin Chiang, An-Louise Johnson, Mailikai Abulikemu, Arnulf Baumann; third row: Walter Guralnick, Carol Lorente, Maria Troulis, Bruce Donoff, Meredith August, Thomas Dodson; fourth row: Thomas Albert, Fardad Tayebaty, Leslie Halpern, Edward Seldin, Sung-Kiang Chuang.
dental school occupied a building on Grove Street, adjacent to the MGH, recently vacated by the Harvard Medical School. It was within this building that the Dental Infirmary of the MGH, the parent of the present Department of Oral and Maxillofacial Surgery, was established. Six dentists and a dental surgeon were appointed to the staff, and it is noteworthy that they treated 4,000 patients a year. In 1909, the Dental School moved to Longwood Avenue, its current location adjacent to the Medical School. An Oral Surgery clinic within the hospital was then established. Leroy M.S. Miner, DMD, MD, who subsequently became dean of the Dental School and Professor of Oral Surgery, was appointed chief of the service in 1924 and remained in that capacity until 1943. Dr Daniel Holland was Miner’s most prominent trainee. 1069
He became Chairman of Oral Surgery at Tufts, and he was president of the American Board of Oral Surgery from 1960 to 1961. In 1942, the school was reorganized and became the Harvard School of Dental Medicine. Dr Kurt Thoma, who had been the Charles Brackett Professor of Oral Pathology, was appointed Professor of Oral Surgery and, in 1943, became chief of the MGH Oral Surgical Service. Thoma’s international reputation brought considerable prestige and recognition to the department. He also established the department’s geographic orientation in the hospital rather than in the dental school. It is important to note that, before Thoma, oral surgeons were not allowed to operate in the hospital’s operating rooms. He broke down those barriers and established a strong and respected service that he headed for 6 years.
1070 Thoma was succeeded in 1949 by David Weisberger, DMD, MD, a 1930 graduate of Harvard Dental School who subsequently obtained his MD degree from Yale University under a Sterling Fellowship. Dr Weisberger’s research interest and expertise were in oral medicine. During his tenure as chief of the service, the name of the department was changed to Oral Medicine even as it continued to accept 1 resident per year for training in oral surgery. In 1965, the Commission on Dental Accreditation (CODA), upon Dr. Weisberger’s petition, allowed the program to accept 2 residents each year. In 1967, upon Dr Weisberger’s death, Dr Walter Guralnick, who had been on the faculty of the Harvard School of Dental Medicine and the MGH since 1950, became department chairman and chief of the MGH service. Dr. Guralnick remained chief until 1983. During his tenure, the hospital agreed to restore the name to Department of Oral Surgery, a descriptor that subsequently changed, in 1979, to oral and maxillofacial surgery (OMFS) in recognition of the broadened scope of the specialty. A full-time faculty of qualified oral surgical specialists was appointed along with part-time oral surgeons to provide both clinical care and teaching. A research program was established and a unique predoctoral teaching experience was initiated. Harvard dental students were all assigned to MGH for a 1-month clerkship in OMFS. This was an undergraduate dental school experience that was unique and continues to be a highlight of the Harvard School of Dental Medicine’s curriculum. To expand the educational content of the residency, 3-month rotations in anesthesia, medicine, and general surgery were established, as well as exchange programs with leading European OMFS centers. A major innovation in oral surgical education was introduced in 1971.
FROM THE TEACHING CENTERS
With the unanimous approval of the Harvard Medical School faculty, a combined 5-year Oral Surgery/MD program was begun. It was originally limited to graduates of the Harvard School of Dental Medicine and ran simultaneously with the traditional 3-year residency. The MD program was predicated upon the conviction that oral surgeons needed more medical knowledge and the same basic general surgical background as all other surgical specialties. Acquiring the MD degree fulfilled the educational requirements and allowed OMFS trainees to serve as full-fledged, licensed general surgical residents for 18 months. The first graduates of the program were Steven Roser (now professor and chairman of OMFS at Emory University), R. Bruce Donoff (dean, Harvard School of Dental Medicine), Leonard Kaban (Walter C. Guralnick Professor, department chair, and chief of OMFS at MGH), and Edward Seldin (associate professor of OMFS at MGH). The 2-track program was eliminated during Dr Donoff’s tenure as chief of the service and further refined by the current chief, Dr Leonard Kaban, so that all residents are now in a 6-year combined degree program. Another significant improvement in the program occurred in 1972, when an affiliation with the Peter Bent Brigham and Children’s Hospitals was established. Dr Kaban became director of OMFS at the Brigham and Children’s Hospitals, and all chief residents rotated through these hospitals for 6 months. OMFS was part of the Division of Plastic and Oral Surgery, headed by Dr Joseph Murray. The affiliation added an important dimension to the training program, providing experience in pediatric and craniofacial surgery performed infrequently at MGH. It also provided a model of collaboration between plastic surgery and OMFS. In 1983, Dr Donoff succeeded Dr Guralnick as chief of the service and chairman of the department at Har-
vard School of Dental Medicine. During his tenure as chief (1983– 1993), Dr Donoff was granted approval to have all MGH OMFS residents accepted into the doubledegree track, thereby eliminating the 2-tiered program. In 1982, the outpatient unit moved into new and expanded quarters in the Wang Ambulatory Care Center. John P.W. Kelly, DMD, MD, was appointed director of the OMFS Outpatient Unit and the Residency Program. Dr Kelly is a graduate of the MGH OMFS Program and subsequently became a leading educator in OMFS. He was president of the American Board of OMFS from 1995 to 1996. Dr Donoff recognized a longstanding need for a dental facility to care for hospital inpatients as well as hospital personnel. After a nationwide search for a dentist to head such a unit, Agnes Lau, DMD, was appointed and the dental program was established as a division of the OMFS Service. In addition, the MGH Dental Unit became part of the Harvard-wide General Practice Dentistry Residency Program based at Brigham and Women’s Hospital. Under Dr Donoff, the research program and clinical activity were expanded. Dr Charles Bertolami, a graduate of the residency program in 1980 and a recipient of a DMedSci degree from Harvard, successfully worked to establish a dedicated Department of OMFS Laboratory at MGH. Subsequently, Dr Bertolami left MGH to become professor and chairman of OMFS at UCLA and then dean of the Dental School at the University of California San Francisco. The laboratory remains in the department and is now the home of the Department of OMFS Skeletal Biology Research Center. To accommodate the increasing complexity and volume of clinical activity, Dr Donoff was granted permission to increase the number of first-year residents from 2 to 3 in 1990. In 1992, Dr Donoff was appointed dean of the Harvard School of Dental Medicine. An ad hoc com-
1071
KABAN AND GURALNICK
mittee was subsequently formed to search for his replacement as chief of service and chairman. In 1993, the Walter C. Guralnick Chair in Oral and Maxillofacial Surgery was established at MGH. In 1994, Dr Kaban was selected to become the Walter C. Guralnick Professor of Oral and Maxillofacial Surgery, department chairman, and chief of the Oral and Maxillofacial Surgery Service at MGH. The Kaban tenure demonstrates yet another expansion of the specialty of OMFS at MGH and mirrors the changes of the specialty nationwide. Dr Kaban’s particular research and clinical interests are in pediatric and craniomaxillofacial surgery. His years at Boston’s Children’s Hospital and the University of California San Francisco provided him with unique knowledge and experience in these areas. In addition, his eclectic clinical and research interests encompass the current broadened parameters of the specialty. In continuation of his early work in skeletal biology, Dr Kaban obtained MGH support to establish the Department of OMFS Skeletal Biology Research Center in 1996. This is a multidisciplinary center, within the department, with participation by the Departments of Surgery and Orthopaedic Surgery. Julie Glowacki, PhD, professor of OMFS and orthopaedic surgery and a longtime collaborator with Dr Kaban, was appointed the first director of the center. This center, currently under the direction of Dr Maria Troulis, focuses on developmental skeletal biology with projects in fetal bone healing, the biology of distraction osteogenesis, tissue engineering of bone and teeth, the effects of inflammation on skeletal wound healing, and minimally invasive surgical techniques. In 1996, with support from Synthes Corporation (Paoli, PA) and the AO-ASIF Foundation (Berne, Switzerland), a Pediatric OMFS Clinical and Research Fellowship was established in the department. Dr Troulis, a graduate of McGill Univer-
sity, Montreal, was the first 2-year Synthes Fellow. She has remained on the faculty of the department and has been instrumental in the development of the research program in distraction osteogenesis, tissue engineering, and minimally invasive surgery. With expansion of the clinical and research programs, Dr Kaban began the recruitment process for a new residency director to provide structure and closer supervision for the trainees. Dr David Perrott was appointed to this position and remained for 2 years. Then, in 1998, Dr Thomas Dodson, DMD, MPH, was appointed unit chief and program director after a nationwide search. Dr Dodson came to MGH from his immediate past position as residency program director at Emory University. Dr Dodson, who practices the full scope of OMFS, is a recognized expert in the field of evidence-based surgical practice, a health care discipline of currently increasing importance. Dr Bonnie Padwa, who is a graduate of Harvard School of Dental Medicine, Harvard Medical School, and the MGH OMFS Program, was recruited to remain on the faculty in 1995, and she is the director of the Longwood Area component of the Residency Program. Dr Padwa is a member of the Craniofacial Center at Children’s Hospital and a close collaborator of John Mulliken, the director. They provide our residents with a unique craniofacial experience. The combination of the Children’s Hospital and MGH Pediatric OMFS experience is unique for a training program of our specialty. This program continues to demonstrate the benefit of collaboration. In the early 1990s, the Harvard School of Dental Medicine class size increased from 20 to 35, necessitating an expansion of the predoctoral program. In 1999, Dr Thomas Flynn was recruited as the director of predoctoral education at Harvard. He has expanded the program on-site at the dental school to accommodate changes in both curriculum and
class size. Dr Meredith August, a 1987 graduate of the MGH OMFS Program, runs the predoctoral MGH externship program for Harvard and visiting students. A major focus of the department has been the development of minimally invasive technologies to improve patient care. These include distraction osteogenesis, tissue engineering, and endoscopic techniques for exposure of the craniomaxillofacial skeleton and treatment of salivary gland disease. Dr Troulis has directed this program, and beginning in 2001, the department has offered a continuing education course: Minimally Invasive Approaches to Mandibular Ramus/Condyle Unit Reconstruction and Salivary Disease. With MGH and international faculty, this course has enrolled OMFS faculty, program and department chairs, and private practitioners to learn these new techniques. Dr Troulis heads an AAOMS task force to develop recommendations regarding the impact of such novel technologies on OMFS training and practice. Under Dr Kaban’s leadership, to improve access to care for all MGH patients and to improve the educational experience of OMFS and general dentistry residents, the Dental Service was expanded to include all dental specialties. A new, dedicated outpatient dental facility was constructed on the MGH campus, and a program for operating room dental rehabilitation of handicapped patients was begun. The MGH Dental Group has grown to include 6 general dentists and specialists in periodontology, prosthodontics, endodontics, pediatric dentistry, and orthodontics. The MGH Oral and Maxillofacial Service is particularly noteworthy for its eclectic scope— teaching, research, and a broad scope of practice from dentoalveolar surgery to all aspects of craniomaxillofacial and tumor surgery. A profile of the service is best found by browsing the
1072
DISTRACTION OSTEOGENESIS FOR CHILDREN WITH MICROGNATHIA
Web site (www.massgeneral.org/ newomfs/) (Fig 2). The MGH program accepts 3 residents each year who are graduates of dental schools throughout the country. The present group of residents includes graduates of the University of Pennsylvania, University of California San Francisco, University of California Los Angeles, University of Connecticut, McGill University, Temple University, Tufts University, Ohio State University, and Harvard, among
others. Acceptance as a resident in OMFS automatically provides advanced standing admission to the Harvard Medical School after the first year of internship. Perhaps the greatest strength of any OMFS department is its faculty. The MGH program has 20 full-time faculty at MGH and affiliated institutions: Brigham and Women’s, Children’s Hospital, Beth Israel Deaconess Medical Center, and Harvard School of Dental Medicine. There also are
26 part-time faculty. This dedicated group has had a significant impact on our students and trainees for generations. The MGH program in OMFS has a strong commitment to diversity, which is reflected in its significant number of women and minorities who are its trainees and staff. It also continues to demonstrate its commitment to continuing requirement and expansion of the art and science of OMFS through basic and clinical research.
Mandibular Advancement by Distraction Osteogenesis for Tracheostomy-Dependent Children With Severe Micrognathia Derek M. Steinbacher, DMD, MD,* Leonard B. Kaban, DMD, MD,† and Maria J. Troulis, DDS, MSc‡ Purpose: The purpose of this study was to evaluate mandibular lengthening by distraction osteogenesis
(DO) to achieve decannulation of micrognathic children with “permanent” tracheostomies. Patients and Methods: Using a retrospective chart review, patients were included who had 1) airway compromise/tracheostomy, 2) micrognathia, 3) polysomnography-documented obstructive apnea, and 4) mandibular advancement using DO. Excluded were 1) adults, 2) neonates without tracheostomy, and 3) patients with central apnea. Patient age, past medical history, age at tracheostomy, and distraction protocol were documented. Oxygen saturation, posterior airway space (in millimeters), and sella-nasion-B point (SNB) angle were recorded. The distraction protocol consisted of a latency of 48 hours and a rate of 1 mm/day. Results: There were 5 children, aged 2 to 14 years, who received a tracheostomy between ages 2 and 36 months for airway obstruction. All patients underwent bilateral mandibular distraction using semiburied, unidirectional devices. The average latency was 58 hours, the rate was 1 mm/day, the duration of fixation was 40 to 60 days, and the magnitude of advancement was 23 mm. Healing was evaluated by clinical, radiologic, and ultrasound examinations. No complications were experienced. Mean follow-up was 3.2 years. Postdistraction sleep studies demonstrated no obstructive apneic events and a mean oxygen saturation of 98% (preoperative, 76%, P ⬍ .005). Cephalometric values improved: posterior airway space 4 to 14 mm; SNB 66° to 72° (P ⬍ .005 for both variables). Four of the 5 patients have been successfully decannulated to date. Conclusions: The results of this preliminary study indicate that mandibular advancement by DO is a potentially viable treatment option for tracheostomy-dependent children with upper airway obstruction secondary to micrognathia. © 2005 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 63:1072-1079, 2005