This past spring, the Tufts Dental Medicine magazine published an article about maxillofacial prosthodontics, or life-changing prosthetics for people who have gone through traumatic disfigurement, external or otherwise. Many of these prosthodontics help patients regain the ability to perform basic functions such as chewing, swallowing or breathing.
The Daily spoke with maxillofacial prosthodontic specialist Sujey Morgan, an associate professor at Tufts Dental School, to learn more about this practice.
The following is an abridged version of the interview.
Tufts Daily (TD): Your research and specialty is in maxillofacial prosthodontics — how did you come up with that focus?
Sujey Morgan (SM): It’s a very small community of maxillofacial prosthodontists around the [United States] and around the world. I was in my teens, and I saw this TV show. And a grizzly bear bit this guy’s face, and [they showed] how the entire team put the face together ... I was in...high school, and I started doing my research and seeing what I need to do in order to be like them ... [There's] a lot of demand, but there [are] not many providers around the world. When I was doing my residency in prosthodontics, I was in a university in Minnesota. I always knew I wanted to do this, but I had more desire during my residency ... You have to be a prosthodontist to be a maxillofacial prosthodontist. So it’s more school, more time, but it’s worth it.
TD: What are some of the difficulties of the work?
SM: One of the hard things of the specialty is that it’s not well-paid. We have a hard time [getting] insurance [companies] to cover the fees that the patients need. For that reason, a lot of prosthodontists don’t want to pursue maxillofacial because it’s a lot of work, a lot of training and the reimbursement is not the greatest ... [Insurance-wise], it’s very hard for a lot of patients…specifically [those] with cancer. They battle the entire disease. By the time they get to us, they face the last step with two issues: they don’t have any more money to cover medical, or the insurance is already too much for treatment.
TD: I imagine over the course of the process that you really get to know the patients — do you keep in touch with the people you help?
SM: We do keep in touch with the people we help … I have a normal practice of prosthodontics, and then I have the maxillofacial [practice] ... The interaction is totally different ... The demands of a patient who is missing a nose or an eye or an entire mouth [are different]. You can give a little piece of paper and cover the hole, and they will be so appreciative. That can result in a stress-free relationship between patient and practitioner — I keep in touch with all the patients I see in the maxillofacial clinic … A lot of these patients are in a lot of pain, sometimes it’s physical pain or pain from the heart. When they have dysphasia [a disorder caused by brain damage that affects the ability to speak] or terminal cancer or [when] they’re born with a missing piece of their face, for some reason, the individual behaves differently than [other patients might], which makes them extremely special. So we do have more of a connection — I would say [there's] more compassion. I love what I do with all my heart. I’ll give you an example ... A patient I have had a chemical burn when he was two years old because he drank a chemical, and I sympathized immediately because I have a two-year-old at home, and so there was a connection immediately … [Maxillofacial patients] always come with a little bit of hope, trying to be able to talk or eat. They’re not asking for much — they’re just asking to be normal.
TD: What’s the timeline like, from a patient requesting a prosthetic to getting one?
SM: It depends on if we’re doing implants. It depends on the healing process, or [on whether or not] the patient receives medication. A prosthesis doesn’t take very long to make, but if [there are complications], it takes time. I can start to finish a prosthesis in three to four months, but sometimes it takes a year because of the wound healing. I would say 90 percent of the patients need my service for the rest of their lives because the prostheses only last six to 12 months. We retouch the prosthesis to make it more [pleasing] to the human eye, or we need to replace it because it needs to be adjusted. A lot of the materials we use for the prostheses disintegrate very fast, so we pretty much see these patients every year for retouching.
TD: In terms of the psychology of it, do people usually adjust to their prosthetics easily?
SM: It depends on how the psychology is affected. There are people who have had this trauma and...don’t care versus [the] patients who will do anything to be normal and to be accepted in society. There are patients who use the prosthesis, and they get used to it since they don’t get the double look. I know patients who only use it for social occasions, and when they’re home they don’t use it … It’s very time-consuming. They have to remove it -- they have to put it back ... Especially for the elderly patients, it’s not that easy ... But I would say when they have something that can help them to speak or to swallow and eat, they’ll do anything to make it work.
TD: What tools do you use? What has been the impact of 3D printing technology on your work, and how have those tools changed?
SM: The technology has changed significantly — the [3D printing] software [currently allows us to] take a digital impression and then the mold can be manufactured in an hour. We don’t have a printer right now, so I need to take the digital impression and send it to a company I work with in California. And then they print the prosthesis, and I can start working with the prosthesis ... Years ago, when the technology wasn’t available...I had to sculpt and do the molding [in wax] by hand. I’ll give you an example: it would take me 40 to 80 hours of sculpting. Now I just take a picture and digital impression, I do a mirror image and I can send it to the company, and they will print the ear right away for me ... They’ll pretty much send us a mold, and I’ll duplicate that and make it in silicon. There’s no silicon-printing machines yet, but there are people working on that at universities. That will be significantly amazing if we can do that in the future because that will mean we can do a prosthesis in two to three appointments. Definitely, the technology we have here — the 3D systems — makes my life much easier and the patients', too … I couldn’t have done it this fast in the past.
TD: With...color mixing, you can get the exact skin tone of the patient — could you talk a bit about that?
SM: There are some pioneering anaplastologists in the U.K. [who have created a technology that is] like a pen with different formulas in the memory ... You turn on the machine and start taking pictures around the skin and around the area you’ll replace. Then, I go to the website and give those numbers, and it gives a recipe. With that recipe, I can mix the colors exactly. I’d say the match isn’t 100 percent, but it’s very close. Before I had to match it by hand, every freckle, and had to mix little colors. It’s pretty amazing — it’ll tell me if I need a little bit of this thickness or this color ... You can get pretty close. You still have to do what we call extrinsic coloring, mimicking a few characteristics, but that was very difficult [in the past].
TD: Is this research under the Dental School and not the Medical School because most of the prosthetics you make are intraoral? Do you ever work with the Medical School on this research?
SM: Our specialty is under the umbrella of dentistry because to be a maxillofacial prosthodontist, first you need to be a dentist then a prosthodontist then a maxillofacial prosthodontist. But I work with a medical team -- I work with EMTs [emergency medical technicians], plastic surgeons, oncologists and pediatric EMTs.
TD: What would you tell people interested in going into maxillofacial prosthodontics? The TuftsNow article said there are seven training programs and 230 trained maxillofacial prosthodontists in the field. Why do you think the field is so small?
SM: I don’t know, to be honest. I just came from the national meeting, and [we’ve got] probably 300-something active members. But a lot of them are retired. One of the things has to be the additional training — you’ve already [gone] to school, then more school, then you have to specialize. When you finish your first residency, you have to go and make money to pay your loans. The other thing is [that] you need to have the heart for this. It’s very hard — you’re not just making prostheses. You’re helping people to live one more day and be accepted and not think about being excluded from society. It can be challenging. The patient who had the chemical burn touched my heart so much ... I think a lot of people go to dental school to avoid that kind of trauma ... You really need to love the work to have this vocation ... I would say I’d get less money if I keep working in maxillofacial than if I keep focusing on my medical practice, but I do it because I love it.
TD: How do you think that trend can be reversed? Is the rotation in maxillofacial prosthodontics for Dental School residents a good first step?
SM: That’s very good — something I’ve been working on with my boss for a long time. We used to have this rotation years and years ago, but it disappeared for some reason … Now we want to expose the residents to how much they can give [by] training in maxillofacial. For example, my second-year residents will be with me [for] eight weeks, and they’ll be exposed to the head and neck conference, [and] to the cleft palate conference ... One of my previous residents is very seriously considering applying to be a maxillofacial fellow ... The more exposure that you get, the more interest you can offer to your residents. I’m really happy with the support that the university is giving to the program and supporting our residents and our patients 100 percent. That’s something very good for us.
TD: What’s the future of your work given that first step?
SM: I want to start a fellowship program at Tufts. That’s my professional goal, and I’ve expressed that [to Dental School administrators]. And we just started a clinic with a few patients. We’re getting to be known in the medical community, and every day we have more referrals and more patients. So my goal is to establish a maxillofacial clinic and create a fellowship program where we can certify maxillofacial prosthodontists at Tufts. In terms of [technology], even though there is a lot, even though we have digital imaging, digital printing, color matching, there’s always a need to find that person who can put those pieces together. The need isn’t disappearing, it’s increasing. Unfortunately cancer is a disease that has no cure yet ... There will always be a need for maxillofacial prosthodontists to assist in the head and neck area.
TD: Is it an expanding field?
SM: I’ve been working at Tufts for eight years, [but] the first time that Tufts residents went to the American Academy of Maxillofacial Prosthodontics meeting [was] last year. And I had two residents there, and that was amazing. They wanted to do a poster, do a presentation … I’m very grateful to the university for that awareness of what we do, so [that now] we have a lot more people interested in the job that we do, a lot more people know we exist ... But all this, at the end of the day it’s about how the patients feel — these prostheses change their lives. That’s what this is about.
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