Dental Art & Science
Maxillofacial prosthodontists help their patients overcome disfiguring trauma and rebuild their lives
Like so many procedures done at Tufts School of Dental Medicine, this one starts with an impression—not of a tooth, though, but of an ear or other facial feature. From that, maxillofacial prosthodontist Sujey Morgan casts an exact replica, in this case, a silicone prosthetic ear for a little boy born without one.
Morgan, an assistant professor of prosthodontics and operative dentistry, has helped restore some normalcy to the lives of more than 30 patients who have needed oral and facial prostheses. Dentists like Morgan help fill a void in Boston’s busy and highly specialized medical enterprise. She and Marcelo Suzuki, an associate professor, are two of just four maxillofacial prosthodontists in the area.
Maxillofacial prosthodontists help patients regain functions such as chewing, swallowing or speech. They also make prosthetic facial features for children with birth defects—such as a missing ear—or for adults who have been disfigured by accidents or cancer surgery. Maxillofacial prosthodontists are often the last resort, Morgan says, when plastic surgery—which requires a certain amount of existing tissue to build on—is no longer an option.
“I’m not six feet under. I couldn’t ask for anything better.” —patient Gregory Cooney
Inside the mouth, maxillofacial prosthodontists can restore sections of the upper or lower jaw and teeth removed during oral cancer surgery. They can fill in a newborn’s congenital cleft palate, allowing the infant to breathe and eat more easily, or they can build new noses ravaged by aggressive skin cancer or acts of violence.
The bulk of the prostheses these dentists make are intraoral—denturelike devices, called obturators, which fit inside the mouth. These prostheses help babies born with cleft palates. More often, they fill the gaps left behind by surgery to remove oral and pharyngeal cancers.
Gregory Cooney’s virulent oral cancer left him without a palate and upper and lower left jawbones. He also lost voluntary muscle control on that side of his mouth. Now in remission after aggressive surgery and radiation treatments, Cooney, 55, could barely speak, eat or swallow when he first came to the dental school.
If she’d had the chance to see him prior to his surgery, Morgan would have done things differently. She would have taken impressions and extracted some of his teeth. But virulent cancers don’t always afford the luxuries of time and the ability to plan ahead.
Instead, Morgan fit him with an obturator that replaced his upper and lower jawbones and plugged the gap where his palate once was. The device added support to the soft tissues on the left side of his mouth and throat and restored Cooney’s ability to breathe more easily, swallow, eat and drink; it also improved his speech.
“I’m not six feet under,” the New Hampshire resident says. “I couldn’t ask for anything better.”
“You can see that many patients feel psychologically that they are very different and that other people won’t look them in the eye and don’t know what to say to them,” says Thomas Vergo, a professor emeritus at the School of Dental Medicine who was director of the division of prosthodontics when he retired in 2004. “My goal was always just to get them back into society on an acceptable level.”
Though Tufts doesn’t offer a formal degree in maxillofacial prosthodontics, the school has been teaching this subspecialty since the mid-1970s. When Vergo joined the faculty, in 1976, he was the school’s—and Boston’s—first board-eligible specialist, having trained in maxillofacial prosthetics at the Roswell Park Memorial Institute in Buffalo, New York. In addition to treating patients, Vergo taught predoctoral students and continues to lecture at other dental schools about the specialty. His goal, he says, was to motivate young health professionals to go into the small, but important field.
“There are just a very limited group of people who treat this type of patient,” says Vergo. “You have to have a special personality.”
In the mid-1990s, Tufts was among the dozen or so schools where dentists could pursue postgraduate training through a fellowship program in maxillofacial prosthodontics. But that ended in 1997, largely due to lack of interested students, Vergo says. Tufts was hardly alone; today there are just seven maxillofacial prosthodontics training programs in the United States and 230 maxillofacial prosthodontists in the country. Vergo is hopeful that Tufts can help reverse the trend.
“I would love to see a dedicated program,” he says. “It’s great we’re providing services for patients, but I’d like to keep the legacy going of training undergraduate and postgraduate dental students as well as training maxillofacial prosthodontists at Tufts.”
The dental school is moving in that direction. When Suzuki joined the faculty in 2007, maxillofacial prosthodontics became part of the postgraduate prosthodontics program. Suzuki assisted on New England’s first facial transplant surgery, performed at Brigham and Women’s Hospital in 2009. Morgan took over for Suzuki full time last year so he could focus on undergraduate teaching.
“I’d like to keep the legacy going of training undergraduate and postgraduate dental students as well as training maxillofacial prosthodontists at Tufts.” —Thomas Vergo
This fall, the school plans to offer rotations in maxillofacial prosthodontics for residents in the prosthodontics program, says Kiho Kang, DG98, DI02, an associate professor and interim director of graduate and postgraduate prosthodontics. Increasingly, Tufts prostho residents have had ample opportunity to gain clinical experience in reconstructive cases referred from several Boston hospitals—Tufts Medical Center, Massachusetts Eye and Ear and Beth Israel Deaconess Medical Center, among them. Long term, Kang says he would like to see Tufts once again offer a fellowship program.
The Artist Within
As a young girl, Morgan saw the victim of a bear attack on television and knew right then that she wanted a career that would allow her to help people who suffer severe facial trauma. The family’s dentist talked with Sujey (pronounced “Sue-hay”) about the long educational path she would have to follow. After she earned her dental degree in her native Colombia, she completed the graduate program in prosthodontics at the University of Minnesota, followed by a fellowship in maxillofacial prosthodontics and dental oncology at the University of Texas MD Anderson Cancer Center.
But she also thought about being an artist. Prior to her prosthodontics training, Morgan studied art welding for a year at the University of Denver. That educational detour would ultimately come in handy.
Part science, part art, custom-designed facial prostheses require a combination of skills—plus a liberal dose of patience. Once the impression of the young boy’s ear dries, Morgan makes a master cast. Using artists’ tools, she sculpts it into a mirror image of a real ear before pouring silicone into the mold to make the prosthesis. The boy had several fittings to ensure his new ear would sit perfectly on his head.
Painting a prosthetic is also an art form. Morgan can streak the tip of an ear with veins or add pores to a nose to make them lifelike. She carefully matches the prosthesis to the patient’s skin tone, mixing paint on a palette daubed with a rainbow of flesh tones.
When it’s finished, the prosthesis is attached to the patient’s face with magnets and medical glue. When there is not enough soft tissue to support the prosthesis—often the case with noses—maxillofacial prosthodontists can incorporate an acrylic base that clips directly to implants attached to the patient’s bone. Then the prosthesis is mounted to this sturdy base, nestled inside the patient’s skull.
Prostheses last only a year or so—and that’s assuming a patient is fastidious about its care. Silicone eventually degrades and can house mold and bacteria, so the delicate synthetic sculpture needs to be kept dry and cleaned with soap and water or rubbing alcohol after every wearing. That’s why some people don’t use them every day.
New scanning and 3-D printing technologies have dramatically reduced the time it takes to fashion a prosthesis. Morgan has used these for her three most recent cases. A digital skin-color scanner that Morgan calls her “new best friend” can instantaneously spit out a recipe for paint that perfectly matches a patient’s skin tone.
People who have had head and neck cancers, including oral and salivary gland malignancies, make up a large portion of maxillofacial prosthodontic patients. These cancers account for 3 percent of all cancer diagnoses in the country, according to the American Society of Clinical Oncology. But these cases, as well as tumors affecting the face, often require some of the most disfiguring treatments.
“The surgeon is just trying to save their lives,” says Morgan.
For these patients, Suzuki says, the maxillofacial prosthodontist also becomes counselor and confidant. “We end up seeing these patients more often than their surgeons,” he says. “They become very attached to you. They ask you things about their treatment that they might not be comfortable asking their other doctors.”
The “before” pictures are arresting—not just because of the disfigurements, but also for the stress that is just as evident, in their eyes, in the set of the mouth, in the slump of the shoulders.
“There’s a mourning for loss of the body part or the loss of function,” says Vergo. “The patient will mourn for that loss until we can put them back together. Our challenge is just to make them a little bit more the way they were, knowing you can never make them totally the way they were. I find it very gratifying.”
Take Sandy Johnson, whose dermatologist missed the significance of a gray spot on the bridge of her nose. A year later, an oncologist diagnosed Johnson with an aggressive squamous cell carcinoma, which by then had spread into her left cheek. Her doctors referred her to Tufts Medical Center, where otolaryngologists Arnold Lee, director of facial plastic and reconstructive surgery, and Miriam O’Leary, an expert in head and neck cancers and reconstruction, removed the malignant tissue. A week before the surgery that saved her life, the doctors, both assistant professors at Tufts School of Medicine, broke the news to her that they would not be able to reconstruct her nose.
“It didn’t sink in what that actually meant,” says Johnson, who lives on Boston’s South Shore.
The morning after the diagnosis, Johnson met with Morgan, who took a cast of her nose. Lying there, still and silent, with the impression material packed on the upper half of her face, Johnson says she felt Morgan’s dental assistant, Nancy Hayward, gently rub her shoulder. “It was such a warm, comforting gesture,” she says. “I just fell in love with them both.”
That was almost a year ago. Now, two surgeries and 30 radiation treatments later, she has been declared cancer-free. But the surgeries left Johnson, 74, with a yawning chasm where her nose used to be.
Just recently, Morgan presented Johnson with not one, but two prosthetic noses she made from the impression she took before her surgery. One is specifically for Johnson to wear to her water aerobics classes. Water is verboten for prostheses. It can set the stage for mold growth and discolor the silicone. But Morgan wanted her patient to feel confident during her favorite form of exercise, so she made a nose just for the pool, skipping the time-consuming painting step.
Scheduled to visit friends and family in California the next day, Johnson could not have been more delighted with her new nose. “I wanted so badly to have it for [the trip]. It looks just like my nose.”
Unlike oral cancer patient Gregory Cooney, Johnson was fortunate in that there was time to take an impression prior to her surgery. “Usually, when I see the patient, it’s too late. There’s no nose, so I have to create a nose,” says Morgan. “So I say, ‘If you like your sister’s nose, bring her in.’ ”
Morgan pulls out an album of before-and-after photos of her patients. The “before” pictures are arresting—not just because of the disfigurements, but also for the stress that is just as evident, in their eyes, in the set of the mouth, in the slump of the shoulders.
“Society can be cruel,” says Morgan. “It’s not that we mean to be, but the first thing we do when we see something weird is take a second look. It’s that second look that can traumatize these patients every day.”