The current status of maxillofacial prosthetic training programs in the United States

Maxillofacial

Prosthetics and Dental Implants m axills nited States

mwegJ. ~~~o~e~

S,a and W. Stuart Dexter, ‘University of Missouri-Kansas City, School of Dentistry, Kansas City, MO. A sumvey

programs. and other ~resentea.~~

was ~o~~~~te~ to examine the current Their r~~atio~s~i~ to private practice, recent changes of merit were evaluated, PEOST'WET DENT ~9%%;?&46%72.)

status of rn~~i~~~~~~~~~ prost compared curriculums, patients, and the res,uks of the survey

are

rosthodonties is truly the art and scienceof dentistry, encompassingal1parameters of treatment. This is especially true when it is applied to the practice of maxillofacial prosthetics (WFP). MFP is one the subdivisionsof prosthodontics; the others are fixed prosthodontics and removable prosthodontics. The American Academy of ~ax~~ofa~~~ Prosthetics wasformed in 1953and became a recognized subdivision. for competency certification in 1967.At present, there are I4 MFP programsin the United States (Figs. 1 and 2). Twelve are offered as l-year programs designedto follow a Z-year prosthodontic program, Two are designedas S-year programs that combine fixed and removable prosthodontics with MFP. The maxillofaciak component is incorporated as the prosthodontic student. progresses. Maxillofadal prosthetics continue to undergo changesas the scopeof available treatment progresses.Better materials and continued refinement of technique make this an exciting area. Patient treatment and status are changing as well. As a result of advancementin surgicaltechniquesand prosthodontic options, patients are treated more extensively, r~hab~~~~ate~ more definitively, and survive longer. This is reflected by changesin managementand care of the axillofacial prosthetic patient and the training programs. en so, not all surgical defects can be satisfactorily repaired surgically, and MFP servicesare still necessary. In 1.962,the American Academy of Maxillofacial Prosthatics decided that a survey to assess the educational status of the s&specialty wasnecessary.The first survey was conducted and reported on in 1966by Laney.’ More recent studieswere cofidueted in !978” and 1986.”To assess recent

changesand the cu.rrent stat-usof S;?;s, ZI:I!ns;~cmenr,s? 10 questions, to be expanded upori, s*-3:de~e?oped.‘I&s survey was designedto look at cierricr&;rrz, patient type, private practice relationship: and okher scent :changes,A correspondencemedium was chosen. According to fbe 1993 ammaErepci?o0n ~d~~~~e~denta1 0scrams in the Enitad education, maxillofacial prasthetics ptsr,le States fall into three categories:tie3taI sc~ooi-based(51, hospital-based (61, and. mi!itaryW& If,‘:. Fmther brenkdown based upon the length of the pr~grsms shops swo lengths: I-year (12) and 3-year (2). Dur:og 5993,the total enrollment in these positions was 24 s~u&nLs in l-year programs aad two stu ents in. 3-year ;:rqrarrs ksr a total of 26 MFP residents or feellows.” A review of the directors of theseprog~a~;sshowsi.hai;of the five dental school-based.programs iietcd by Ihe hmwieanDental Association (ADA)? two are ~~~~~-~e~~~e~ ar,d SCl~OOl three are educationally qualified. -iihc n:-~r~-den~l21 programsare directed by eight f-&-time an2 one part-t” instructors. @f theseinstructors, seven,ire board-cert:

---Presentedbeforethe AmericanAcademyof Maxillofacial Pros-

cleft

thetics, Palm Springs, Calif.

aH.G. B. RobinsonProfessorand Chair,Departmentof RemovableProsthodontics. “As&tact Professor,Departmentof RemovableProsthodontics. Copyright8 EC%84 by The Editorial Councilof THE tJ~~:~~~~. OF PRO~TI~X

DEPJT~~FRY.

and two me e~~~~t~o~~l~y

qualifiec”.

The generabcurriculum for all programsWEBfairly consistent with relations through--or 2SSi~~~~.~~%~~~,S in----pliestic surgery, diagnosticand the~‘a.peut~ -- -EKli.alagy> 6 ~~e-m2t{)~c~y/ oacology, cleft palates, study eiu$s, hkxwif. reviews, and out-of-service roeatiorls.

lita-aiure

Major changesthat, have oecurrcc~. SWI-i.2.epast 10years are the losscf two programsand Ge i‘ormation of three new p:rogr-rzns. There is continued ~~~~~~~~7~~~~~~. in formal. out*lines 2nd refinement of programs. Matik& 5eienceis reported as a constantly upgraded.subje& The number oi’ palate

reported

patients

continues

to det:ri?ase.

Zmplants

as the most majors chsngc: in i.w:ent years,

ai:

THE JOURNAL

OF PROSTHETIC

Fig.

LOCATION

MOORE

DENTISTRY

1. Location

of maxillofacial

OF MAXILLOFACIAL

1. Dr. Kirk Gardner, Director Maxillofacial Prosthetics Program University of Alabama School of Dentistry UAB Station Birmingham, AL 35294 One-year program 2. Dr. C. A. Andres, Director Maxillofacial Prosthetics Program Indiana University Medical Center 1121 West Michigan St. Indianapolis, IN 46202 Three-year program 3. Dr. John Beumer, Director Maxillofacial Prosthetics Program University of Southern California School of Dentistry 925 W. 34th St.-Univ. Pk. MC0641 Los Angeles, CA 90089-0641 One-year program 4. Dr. S. Eckert, Director Mayo Graduate School of Medicine 200 First Street, S.W. Rochester, MN 55905 Three-year program

prosthetic

PROSTHETIC

training

TRAINING

7. Dr. Dorsey J. Moore, Director Maxillofacial Prosthetics Program University of Missouri-Kansas City School of Dentistry 650 East 25th St. Kansas City, MO 64108 One-year program 8. Dr. Norman Schaaf, Director Maxillofacial Prosthetics Program Roswell Park Memorial Institute 666 Elm St. Buffalo, NY 14263 One-year program 9. Dr. Ian Zlotolow, Director Maxillofacial Prosthetics Program Memorial Sloan-Kettering Hospital 1275 York Ave. New York, NY 10021 One-year program

470

2. Addresses

DEXTER

(graphic).

PROGRAMS 10. Dr. B. Valauri, Director Maxillofacial Prosthetics Veterans Administration 423 East 23rd Street New York, NY 10010 One-year program

6. Capt. E. Monaco, Director Maxillofacial Prosthetics Program Naval Dental School 8901 Wisconsin Ave. Bethesda, MD 20889 One-year program

Program Medical Center

11. Dr. Y. Ismail, Director Maxillofacial Prosthetics Program University of Pittsburgh School of Dental Medicine 3501 Terrace St. Pittsburgh, PA 15261 One-year program 12. Dr. Donald Kramer, Director Maxillofacial Prosthetics Program University of Texas M.D. Anderson Hospital 1515 Holcombe Blvd Houston, TX 77030 One-year program 13. Dr. R. Knudson, Director Maxillofacial Prosthetics Program Wilford Hall USAF WHMC/SGDO Suite 1 Lackland AFB, TX 78236 One-year program 14. Dr. J. Toljanic, Director Maxillofacial Prosthetics Program University of Chicago Zoller Dental Clinic 58415 Maryland Ave.-MC2018 Chicago, IL 60637 One-year program

5. Dr. William LaValle, Director Maxillofacial Prosthetics Program University of Iowa Hospital Department of Otolaryngology Iowa City, IA 52242 One-year program Fig.

programs

AND

of maxillofacial

prosthetic

training

programs.

VOLUME

72

NUMBER

5

cl!-------

-Cancer

-i-mu Fig. 3. Location

of defect.

60435% Avg. 76%

Fig. 4. Causes of defects.

defects, involvement with cleft lip/cleft palate treatment, t.umos boards, literature reviews, and study clubs. Guidelines inc!ude rotations through the specialties involved with treatment such as plastic surgery, head and neck surgery, radiation, and chemotherapy/oncology. Wi.th the exception of the new programs, the most significant program change over the past 10 years is the ition of the use of implants. Most implant procedures have been intraoral, but extraoral implants are slowly being incorporated into accepted protocol. Another major iactor aflecting prosthetic rehabilitation has been the recent advancement in microvascular and reconstructive surgery. This has led to an increase in options for the patient and the restoring prosthodontist. There continues to be refinemeE.t of lectures, literature reviews, and increasing hasis on research A continuing decrease in the number of patients with cleft lip and cleft palate was reported 3-i this survey. The types of patients treated were divided into two categories, (I] cause of defect-cancer, trauma, congenital; and (2) location of defect--intraoral or extraoral. The per-

The types of patients that programs r+:pnrt as dif-fiell”rt to provided a wide range of sile‘-~e;~~re~gjonses, Some programs reported no problem findi ng all types 01’ patienta. Patients needing prosthodortic aervkes for unrepaired cleft palates were difhcult to find for XI:~~~S~Eprograms. Ccular defects and combination defect.~ ;iratraoraE and extfaoral) were dso reported to be seaIce. Because of hospital arrangements and loeationl, 3~.zrna patients were also scarce. The nilmber ol patients req;sjring r&&ilixtion t%r discontinuity d.efects has also dimiz:ished. Some pmbSems are related to the newness of prssga~s or a reflection of changes in surgical treatment for som? patients. This may be resulting in fewer unrepaired surgical defeeLs. Hmpimt patients remain in short supply :‘or eeveral reas‘ons. Firzances can be a problem, and many or he cancer patients

THE

JOURNAL

OF PROSTHETIC

MOORE

DENTISTRY

AND

DEXTER

Intraoral 20%of cases 30% of cases completed with implants

70%of cases

80%of cases completed without implant

Fig. 5. Intraoral implant usage.

Fig. 6. Extraoral implant usage.

have beentreated with high levels of radiation and are not ideal candidates to receive implants. Patients pay for these servicesin several ways. Most institutions report a combination of payment options including private insurance and Medicaid or Medicare. Patients seenin military institutions are covered by military benefits. A certain number of rehabilitation patients are unable to pay. These casesare generally rehabilitated free of charge and are viewed as teaching cases.This practice is justified asa way of maximizing the learning experiencefor the resident, especially if the defect is of a type that is seldom seen. The effect of implants on programsis still modestat this point. Most dentists agreethat implant systemsallow for altered methods of retention, support, and stability, and there hasbeen an increasein implant didactics. Most programsare using intraoral implants to someextent, but the use of extraoral implants is still in the initial stages(Figs. 5 and 6). Stipends ranged from $27,000 to $45,000per year depending on the cost of living and area. There is somedependency on the level at which a resident comesinto the program (years of postgraduatetraining). The averagestipend was approximately $32,000. The question of the uniquenessof eachprogram and the number of applicants for eachposition received a wide variety of responses.These responsesreflected what was considered the program’s strong points when compared with other programsand varied widely from having a fully integrated 36-month program that allowed a resident to follow both successes and failures to a low student/faculty ratio, to having a large patient pool from which to draw, to providing broad-based services. Federal programs were able to provide theseservicesto the patient without severe financial concerns,avoiding one of the problemsof private institutions. The number of applicants for positionsranged from 2.5/l to 30/l, with most averaging approximately 5 6/l. It wasin this phaseof the survey that the question was raised, “HOW many maxillofacial prosthodontists are

needed and how could this need be assessed?”This is an area where further study is obviously needed. There was minimal preparation regarding how fellows and residents are prepared for entering private practice. Most reported the clinical training and acquisition of technique diversity as strong points. Some experience was gained in computers and database operations, but there was minimal exposure in the insurance claims processreported, although someprogramsdo offer coursesin practice managementskills. Future plans for most programs involve yearly updates. Establishedprogramscontinue with further refinement of coursesand teaching skills asopposedto major changesin protocol. Most plan to expand implant servicesin the future. In addition, didactics will continue to increaseasthe knowledge baseexpands. Current maxillofacial prosthetic programsoperate with the samegoalsin mind: to provide a much neededservice to patients and to provide residentswith the greatestamount of experiencepossible.The methodsof accomplishingthese criteria vary widely. As patient needsand demandschange, somust the field of maxillofacial prosthetics.It will be mandatory to determinethe direction this field isheadedandhow bestto guide it into the 21stcentury.

472

REFERENCES 1. Laney WR, Draws JB, Rosenthal LE. Educational status of maxillofacial prosthetics: report of the education survey committee of the American Academy of Maxillofacial Prosthetics. J Am Dent Assoc 1966; 73:647-51. 2. Chailian VA. Education in maxillofacial prosthetics. J PROSWET DENT 1978;40:579-82.

3. Desjardins PROSTHET

RF. Maxillofacial DENT

prosthetics:

4. American Dental Association. Department Annual report on advanced dental education, ican Dental Association, 1992. Reprint

requests

demand

and responsibility.

J

1986;56:473-7.

of Educational Surveys. 1992-93. Chicago: Amer-

to:

DR. DORSEY J. MOORE UNIVERSITY OF MISSOURI-KANSAS SCHOOL OF DRI~TISTKY 650 EAST 2.3~~ Sr. KANSAS CITY, MO 64108

CITY

VOLUAMR

72

NUMRER

5