The future of maxillofacial prosthodontics in North America: The role of advanced digital technology and artificial intelligence - A discussion document.

STATEMENT OF PROBLEM: Maxillofacial prosthodontists were advanced digital technology (ADT) adopters early in the new Millennium. The past two decades saw a range of digital enablers emerge including digital imaging (internal and surface), digital surgical planning, digital functional assessment, subtractive and additive manufacturing, navigation, and robotics among others. Artificial Intelligence (AI) is the latest ADT arrival that will be a challenging disruptive technology. ADT has served as a profound change agent in maxillofacial prosthodontics. The intent was to explore the process and level of ADT engagement in maxillofacial prosthodontics. PURPOSE: The purpose was twofold. Firstly, to explore maxillofacial prosthodontic engagement of ADT. Secondly, to develop a discussion document to assist the American Academy of Maxillofacial Prosthetics (AAMP) with establishing a collective awareness and considered opinion on the future of maxillofacial prosthodontics in the digital era. MATERIAL AND METHODS: AAMP member interest in ADT was assessed through analysis of AAMP annual congress programs and publications in the Journal of Prosthetic Dentistry (JPD). The history of the maxillofacial prosthodontic journey to the digital era was undertaken with a selective literature review. The perceptions maxillofacial prosthodontists hold on ADT engagement was assessed through a survey of AAMP members. Developing an understanding of the influence AI was conducted with a review of pertinent literature. RESULTS: From 2011-2020, an annual mean of 38% of papers published in the JPD involved clinical use of ADT. From 2017-2019, 44% of invited presentations at AAMP annual congresses included clinical use of ADT. The journey to the digital era distinguished three periods with formative and consolidation periods influencing the innovation digital era. The AAMP member survey had a 59% response rate and studied 10 domains through 31 questions. Of the respondents, 89% thought ADT important to the future of maxillofacial prosthodontics. CONCLUSIONS: The discussion document will assist the AAMP in developing a collective consciousness and considered opinion on ADT in the future of maxillofacial prosthodontics. Members of the AAMP have a developed interest in clinical applications of ADT. A great challenge is that no formal education, training, or clinical competency requirements for ADT could be identified. Clinical competency requirements are important to prepare maxillofacial prosthodontics for the inevitability of a digital era future. The discussion document poses the fundamental question of whether maxillofacial prosthodontists will remain as passive end users of ADT and AI or will they become engaged knowledge workers that have determined clinical competency in ADT and AI in patient care. Without this knowledge worker role, maxillofacial prosthodontists may experience difficulty being part of the inevitable ADT-AI driven future.

The future of maxillofacial prosthodontics in North America: Part II - A survey.

STATEMENT OF PROBLEM: 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: 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: 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.

The future of maxillofacial prosthodontics in North America: Part I-Journey to the present.

STATEMENT OF PROBLEM: 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: 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: 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.

Long-Term Follow-Up of Osseointegrated Orbital Prosthetic Reconstruction.

BACKGROUND: Osseointegrated implants have been used for craniofacial prosthetic reconstruction since 1979. The authors sought to review long-term outcomes of osseointegrated orbital reconstruction at the Institute for Reconstructive Sciences in Medicine (iRSM). METHODS: Twenty-six patients have undergone osseointegrated orbital prosthetic (OOP) reconstruction at iRSM since 1991. A retrospective chart review was performed and patient satisfaction assessed through a questionnaire used in previous osseointegration studies. Multivariate binary logistic regression analysis was performed to assess the relationship between smoking, age, sex, and previous radiation treatment with the occurrence of skin reactions and implant failures. A χ test was used to assess the relationship between implant position within the orbit and development of a skin reaction or implant failure. RESULTS: Patients received an average of 5.8 implants during the course of treatment. Follow-up ranged from 6 months to 24 years (mean = 10.6 years). A statistically significant correlation was found between skin reaction and age (P = 0.022), with younger patients more likely to develop a reaction. No variables in our model were significant for predicting implant failure. Overall, there were 39 failures of 155 osseointegrated implants, for a success rate of 74.8%. There was no relationship between skin reaction and implant failure compared to implant position within the orbit. Survey responses were received from 11 of 19 patients (58% response rate). Ninety-one percent of patients were overall satisfied with their prosthesis. CONCLUSIONS: There are minimal contraindications for consideration of OOP reconstruction. Patients find their prosthesis comfortable, report increased self-confidence, and are happy to have undergone reconstruction.

A review of functional outcomes related to prosthetic treatment after maxillary and mandibular reconstruction in patients with head and neck cancer.

PURPOSE: This review examined literature that reported functional outcomes across 3 categories of prosthetic treatment after microvascular reconstruction of the maxilla and mandible: (1) conventional dental/tissue-supported prosthesis, (2) implant-retained prosthesis, and (3) no prosthesis. MATERIALS AND METHODS: Library databases were searched for articles related to reconstruction of the maxilla and mandible, and references of selected articles were hand searched. Relevant literature was identified and reviewed with criteria specified a priori. RESULTS: Forty-nine articles met the inclusion criteria. Twelve articles reported on function after maxillary reconstruction, with the majority of articles reporting on outcomes for 1 to 6 subjects. Thirty-nine articles reported on function after mandibular reconstruction. Speech outcomes were satisfactory across all groups. Swallowing reports indicated that many patients who received either type of prosthetic rehabilitation resumed a normal diet, whereas those without prosthetic rehabilitation were often restricted to liquid diets or feeding tubes. Patients without prosthetic rehabilitation reportedly had poor masticatory ability, whereas conventional prosthetic treatment allowed some recovery of mastication and implant-retained prosthetic treatment resulted in the most favorable masticatory outcomes. Quality-of-life outcomes were similar across all patients. CONCLUSIONS: Several limitations of the current literature prevented definitive conclusions from being reached within this review, especially regarding maxillary reconstruction. However, recognition of these limitations can direct functional assessment for the future.

The rapid prototyping of anatomic models in pulmonary atresia.

OBJECTIVE: The goal of this study was to assess the utility and accuracy of solid anatomic models constructed with rapid prototyping technology for surgical planning in patients with pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries. METHODS: In 6 patients with pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries, anatomic models of the pulmonary vasculature were rapid prototyped from computed tomographic angiographic data. The surgeons used the models for preoperative and intraoperative planning. The models' accuracy and utility were assessed with a postoperative questionnaire completed by the surgeons. An independent cardiac radiologist also assessed each model for accuracy of major aortopulmonary collateral artery origin, course, and caliber relative to conventional angiography. RESULTS: Of the major aortopulmonary collateral arteries identified during surgery and conventional angiography, 96% and 93%, respectively, were accurately represented by the models. The surgeons found the models to be very useful in visualizing the vascular anatomy. CONCLUSION: This study presents the novel vascular application of rapid prototyping to pediatric congenital heart disease. Anatomic models are an intuitive means of communicating complex imaging data, such as the pulmonary vascular tree, which can be referenced intraoperatively.

Misfit and functional loading of craniofacial implants.

PURPOSE: This study sought to develop an understanding of the magnitude and types of loads generated on craniofacial implants supporting an auricular prosthesis. MATERIALS AND METHODS: Strain gauges were used to measure the in vitro and in vivo misfit loads generated when connecting auricular-style superstructures to implants and the in vivo functional load generated during the removal and insertion of the auricular prostheses. In addition, the vertical misfit of the 11 custom-built two-implant superstructures used in the in vitro study was measured. RESULTS: Superstructures used in the in vitro study that were considered clinically passive still had considerable preloads. In addition, the calibrated loads, which would result from the vertical misfit alone, did not account for the magnitude of the generated preloads. CONCLUSION: The clinical definition of misfit based on vertical distortion of the superstructure did not quantify the resulting misfit load. Measured in vivo functional loads were smaller than the misfit loads.

Prosthodontic rehabilitation of a patient with total avulsion of the maxilla: a clinical report.

Patients with complete avulsion of the palate may require extensive surgical and prosthodontic rehabilitation. The prosthesis should replace not only missing teeth but also lost soft tissues and bone, including the hard palate, residual alveolar ridges, and in some situations, the soft palate. This clinical report describes the prosthetic rehabilitation, after appropriate surgical options had been exhausted, of a patient with bilateral traumatic avulsion of the maxilla.