FOSTERING INTERDISCIPLINARY, PATIENT-CENTERED CARE
FOSTERING INTERDISCIPLINARY,PATIENT-CENTERED CAREINCORPORATING THE LATEST TECHNOLOGY, RESEARCH, ANDINTEGRATED CARE, THE DEPT. OF ORAL & MAXILLOFACIALSURGERY IS MAKING PATIENTS WHOLE AGAINABOVE: Pre-operative and post-operative 3D-stereolithographic models of a patient with a benign tumor ofthe right mandible. Faculty of the Department of Oral &Maxillofacial Surgery/Pharmacology use such modelsfor patient education in advance of a surgery, as well asfor pre-surgical treatment planning and as an adjunctduring surgery to aid in decision-making.16 WWW.DENTAL.UPENN.EDUORAL AND MAXILLOFACIAL surgeons,by the very nature of their specialty, oftenwork with colleagues across many disciplinesto achieve optimal outcomes for patients.Think about it — a patient being treated fora tumor in her jaw might require a team thatincludes radiation and medical oncologists,pathologists, oral medicine specialists, prosthodontists, endodontists, speech therapists,dieticians and social workers, just to namesome of those who may be involved in thispatient’s care.The importance of this interdisciplinary,collaborative approach is evident in theDepartment of Oral & Maxillofacial Surgery/Pharmacology at Penn Dental Medicine,where many faculty members have bothdental and medical degrees and hold jointappointments at Penn Dental Medicine andPenn Medicine to further facilitate a highlevel of interaction with other specialists. Infact, this year marks a milestone exemplary ofthese interprofessional ties: the 25th year ofestablishing a Department of Oral & Maxillofacial Surgery at the Hospital of the University of Pennsylvania (HUP) (see sidebar, p. 19).Now, under the leadership of Chair Dr.Anh Le, Norman Vine Endowed Professor ofOral Rehabilitation, the School’s Departmentof Oral & Maxillofacial/Pharmacology is carrying out an ambitious plan to incorporatethe latest research, technology, and integrated initiatives in academics, research, andclinical care, Dr. Le says, “expanding eachcomponent to elevate and grow the department and to provide a world-class clinicalexperience to our patients at Penn.”On the clinical side, one major way Dr.Le is fostering this approach is through thedevelopment of “centers” or clusters of patient
care in specialized areas. She explains that thegoal is to provide safer, more precise, personalized therapies that will result in faster function recovery, improved esthetics and health,and overall, a better quality of life. In the lastfew years, Dr. Le has established three suchcenters: one focused on temporomandibularjoint disorders, headed by Dr. Eric Granquist,Assistant Professor of Oral & MaxillofacialSurgery/Pharmacology; another on orthognathic and corrective surgery, led by Dr. LeeCarrasco, Clinical Associate Professor of OralMaxillofacial Surgery/Pharmacology; and athird center addressing trauma and reconstructive surgery, headed by Dr. Neeraj Panchal and Dr. Steven Wang, both Instructors ofOral & Maxillofacial Surgery/Pharmacology.Now, the newest center for patient careis targeting oral and dental rehabilitationfor head and neck cancer patients, anchoredby the expertise of the department’s newestmembers — oral maxillofacial surgeon Dr.Rabie Shanti, who specializes in tumorresection and reconstruction, and maxillofacial prosthodontist Dr. Brian Chang, whosework includes restoring missing teeth, facialtissue, and eye sockets for patients impactedby these cancers.This new center, Dr. Le says, “willprovide comprehensive patient care with amultidisciplinary, highly experienced teamof dentists and surgeons to work on preservation, maintenance, and restoration of oralhealth for tumor resection.”INNOVATIVE TECHNOLOGY TO AIDSURGICAL PRECISIONThese clinical efforts are further supportedby a departmental focus on utilizing the mostadvanced technology available, includingstate-of-the-art 3D printing and digitalscanning and incorporating digital tools toexactingly plan and carry out these complexsurgical procedures with the greatest degreeof precision and efficiency. In collaborationwith several Penn Medicine departments, Dr.Le notes that they hope to bring 3D printingand digital scanning capabilities on site in2018; presently, while these technologies areused in patient care within the department,the 3D printing and scanning are contractedwith an external lab.By using virtual surgery planning, Dr.Shanti says, “I can get on a computer withimages of the patient, design the surgery, simulate it, and identify where I’m going to makethe cuts, how the tumor is going to comeout, and how I’m going to rebuild the jaw.”This technology allows for the fabrication ofcustomized materials — cutting guides andplates specific to each patient. “It not onlyhelps increase the precision and accuracy ofthe surgery,” he says, “but it also minimizesthe time we spend in the operating room.”One recent patient was a 59-year-oldwith an ameloblastoma that involved threequarters of her upper jaw and her entire hardpalate, as well as the sinuses and inner nose.“Removing large tumors of the maxilla andpalate requires consideration of the nose, eyesocket, sinuses, and the skull base,” Dr.Shanti says. “Therefore, this technologyallows me to consider every millimeter of thesurgery in preparing for where I am goingto make my bony cuts in order to removethe tumor safely and without compromisingclearance of the tumor.”ABOVE: Dr. Rabie Shanti (left)and Dr. Brian Chang(right) are leading the Department’s oral and dentalrehabilitation center for head and neck cancer patients.LEFT: Dr. Lee Carrasco, GD’02, (left) heads theDepartment’s patient care centered on orthognathic andcorrective surgery, with Dr. Eric Granquist, M’07, GD’10,RES’10, (right) focuses on temporomandibular jointdisorders.PENN DENTAL MEDICINE JOURNAL FALL 2017 17
INTERDISCIPLINARYCAREDuring the same operation, the patienthad her upper jaw defect reconstructed withbone, muscle, and skin tissue from her forearm. Within a week, she had left the hospital,was eating fairly normally, and movingtoward having a denture fabricated with thelong-term goal of having dental implants.Although relatively rare — only one casein two million people — ameloblastomas arethe most common benign tumors of the jawand Dr. Shanti sees a significant number ofcases. “We know very little about this tumor,”he says.Thus, developing better options to treatthe destruction caused by these benigntumors, which don’t respond to chemotherapyand often require major surgery to removeand rebuild the jaw, is of particular interestto him. And in the Oral and MaxillofacialSurgery lab, Dr. Shanti is working to betterunderstand what drives ameloblastomas.His long-term goal is to develop non-surgicaltreatment options and to design new structures through tissue engineering that willmore effectively replace the tissues hispatients lose during surgery, whether due totumors, trauma, or other medical conditions.He’s aiming to find a better option — forinstance, by helping patients regrow theirown tissue rather than harvesting part of apatient’s own body for reconstruction.“[This technology] not onlyhelps increase the precisionand accuracy of the surgery,but it also minimizes thetime we spend in theoperating room.”— DR. RABIE SHANTI18 WWW.DENTAL.UPENN.EDUABOVE: 3D images from virtual surgical planning (VSP) sessions, showing the planningof a mandibular tumor resection while also incorporating fibula free flap reconstruction.“I think we’re on the cusp with tissueengineering and using engineered stemcell-based constructs to reconstruct tissuesof the head and neck,” he says. “I think that’sgoing to be a really significant advancementin reconstructive surgery that I hope to bea part of.”Dr. Shanti, assistant professor at bothPenn Dental Medicine and the Departmentof Otorhinolaryngology/Head and NeckSurgery at Penn Medicine, has broughtdeep interdisciplinary expertise to Penn. Heattended dental school at Harvard University,spending two years as a Howard HughesMedical Institute research scholar workingin an orthopedics laboratory at the NIH’sNational Institute for Arthritis and Musculoskeletal and Skin Diseases, where he focusedon tissue engineering and designing newmaterials to regrow muscle and bone.He then pursued his MD and residencyin oral and maxillofacial surgery at RutgersUniversity, followed by a two-year fellowship at Louisiana State University, where hegained considerable experience in microvascular reconstruction surgery — taking tissuesand blood vessels from one part of the bodyand connecting them as living tissue inanother part of the body. The opportunity towork in a comprehensive and collaborativeclinical and research environment that ispatient-focused brought him to Penn in 2016.“There is no area of medicine as multidisciplinary as caring for a patient with oralcancer,” Dr. Shanti says. “In one patient, 15specialists can be involved, and we go overeach case together,” he notes. “For a patientwith oral cancer, the diagnosis is already overwhelming, and we provide a patient-centeredrather than practitioner-centered approach.”
PROVIDING PROSTHETICRECONSTRUCTION FOR PATIENTSCo-leading this new center is Dr. Chang,associate professor and Director ofMaxillofacial Prosthodontics, who has jointappointments in both the Dept. of Oral &Maxillofacial Surgery/Pharmacology andDept. of Preventive and Restorative Sciencesat Penn Dental Medicine. He also holds anappointment at Penn Medicine.Since coming to Penn earlier this year,Dr. Chang has been teaching in Penn DentalMedicine’s new residency program in prosthodontics and sees patients at the ClinicalPractice of the University of PennsylvaniaDept. of Oral & Maxillofacial Surgery at HUP.Spanning these roles, his responsibilitiesinclude the care of medically compromisedpatients who need prosthetic reconstructiondue to disease or trauma, organization of themaxillofacial prosthodontic clinic, residenteducation, and research. He also consults aspart of the head and neck cancer team andworks with colleagues across a variety ofmedical and dental specialties.Prior to joining Penn, Dr. Chang washead of the Section of Maxillofacial Prosthodontics at the Cleveland Clinic and directorof predoctoral prosthodontics at Harvard’sSchool of Dental Medicine. He did a residency in prosthodontics at NorthwesternUniversity and a fellowship in maxillofacialprosthodontics at Columbia University.His research interests include theclinical outcomes of dental implants for headand neck cancer patients and the applicationof novel 3D technologies for surgical andprosthetic reconstruction for patientswith head or neck cancer or craniofacialanomalies. He also has a particular interestin curriculum development.“Research of head and neck cancer andcraniofacial anomalies has been rapidlygrowing through the interactions betweenclinician-oncologists, basic scientists, speechand language pathologists and engineers,”Dr. Chang says. “I have also been working onoutcome assessments of quality of life andphysiologic functions, such as speech, deglutition, and swallowing, for patients with headand neck cancer or craniofacial anomalies.”25 Years within HUPTHIS YEAR MARKS a milestone exemplary of theinterprofessional ties of the School’s Department ofOral & Maxillofacial Surgery/Pharmacology — the25th anniversary of establishing a Department ofOral and Maxillofacial Surgery at the Hospital ofthe University of Pennsylvania (HUP).In 1992, Dr. Peter Quinn, then Chair of PennDental Medicine’s Department of Oral and Maxillofacial Surgery/Pharmacology, was also namedChair of the newly created Department of Oraland Maxillofacial Surgery and Hospital Dentistryat HUP. This independent departmental statusfacilitated the growth and integration of the oraland maxillofacial surgery and oral medicine facultyacross Penn Medicine.It paved the way for an “ambitious renovationand expansion of the program,” Dr. Quinn says,further shoring its reputation as a “premier program for education, research, and patient care.” Dr.Quinn, who remained Chair of the department until2008, is presently Schoenleber Professor of Oral& Maxillofacial Surgery/Pharmacology; Vice Deanfor Professional Services, Perelman School of Medicine; and Senior Vice President for the University ofPennsylvania Health System.Growth was evident with the number offull-time Department faculty increasing from fourin 1994 to 15 today. The Department at HUP waslocated within the hospital’s White Building until2012, when it moved to its current home within thePerelman Center for Advanced Medicine.ABOVE: Dr. Anh Le, Chair, Dept. of Oral & Maxillofacial Surgery/Pharmacology, with Dr. Peter Quinn,Schoenleber Professor, who was Chair when an Oral& Maxillofacial Surgery Department was firstestablished at HUP 25 years ago.Establishing the department at HUP reflecteda general trend of addressing more complex medicalcases in a hospital setting, facilitating collaborationwith other specialists. “We are a very interprofessional group,” Dr. Quinn says of oral surgeons.“Most of us have medical and dental degrees; westraddle two professions and have always had apresence in both the dental school and hospital.”A highlight during this time was Dr. Quinn’swork on the Zimmer-Biomet TemporomandibularJoint (TMJ) Replacement System, which receivedFDA clearance in 2005 and is still the onlyFDA-approved stock prosthesis in the U.S. “It tooksix years to develop, followed by a 10-year clinicaltrial,” he says. “You need to be in a place like Penn,that can draw enough patients to power the studyand has the research infrastructure” to bring aboutsuch advances.Now, with the help of computer-guidedsurgery and 3D-printing technology Dr. Quinnexpects more opportunity to create custom TMJprostheses for patients.But, he predicts that future advances inthe field are likely to come from the innovativeresearch being done in the Department todayunder the leadership of the current Chair, Dr. AnhLe. “There has been an explosion both in basicscience and on the translational side in the last 25years,” Dr. Quinn says. Rather than looking at waysto make better prostheses, he says, leading-edgeresearch is focused on engineering a patient’s owntissue to genetically replace what they lose. “That’sthe next frontier,” he says.PENN DENTAL MEDICINE JOURNAL FALL 2017 19
INTERDISCIPLINARYCAREDepartment FacultyChairmanAnh D. Le, DDS, PhD, Chair and Norman VineEndowed Professor of Oral Rehabilitation; Departmentof Oral & Maxillofacial Surgery/PharmacologyFull-Time FacultyLee R. Carrasco, DDS, MD, Clinical AssociateProfessorBrian Myung Chang, DDS, FACP, FAAMP, AssociateProfessor of Clinical Restorative Dentistry; AssociateProfessor of Clinical Oral Surgery and Pharmacology;Director, Maxillofacial ProsthodonticsBrian Ford, DMD, MD, InstructorNEW RESEARCH-FOCUSEDRESIDENCY OPTIONIn addition to establishing these clinical centers of expertise, the department also recentlyreceived approval to expand the department’sresidency program, directed by Dr. HelenGiannakopoulos, Associate Professor (above,left). There are currently three residents peryear in the six-year, dual-degree Oral andMaxillofacial Surgery/MD program, who receive a medical degree from Penn Medicine,a two-year certificate in general surgery andcertificate in oral and maxillofacial surgery.Starting next year, a fourth resident will beadded along with the option for residentsto additionally pursue a Doctor of Sciencedegree, taking about two years longer tocomplete this research-focused degree. Theintention Dr. Le says, “is to teach futuregenerations of surgeons who can integratemore evidence-based, innovative scientificfindings into their practice.”“The intention is to teachfuture generations ofsurgeons who can integratemore evidence-based,innovative scientific findingsinto their practice.”In the realm of research, among the areasof particular focus within the department isregenerative medicine. Since coming to PennDental Medicine in 2012 from the University ofSouthern California’s Ostrow School of Dentistry, Dr. Le has continued her research on mesenchymal stem cells from adult oral gingivaltissues (also known as GMSC), and how theymight aid in wound healing and regeneratingof lost tissues from either trauma or pathologies. She is also studying their potential for usein nerve and tissue regeneration, which couldhelp, for instance, a patient who has had partialtongue removal due to cancer or injury.“The Oral and Maxillofacial Surgery labis focused on translational/clinical researchin regenerative medicine of the orofacialstructure. An active project is to develop aneural construct using GMSCs, looking atnerve regeneration, nerve injury pathology,trauma, and tumor resection,” says Dr. Le.Although she says clinical human trials areat least a decade away, this research holdspromise for head and neck cancer patientsin need of reconstructive surgery followingtumor resection with resulting nerve injury.These promising areas of research,along with new initiatives in education andclinical care, are all intended to support thedepartment’s overarching goal, Dr. Le says, ofproviding a “comprehensive and integratedapproach to delivering the highest qualityand personalized care to patients.”— DR. ANH LE— By Debbie Goldberg20 WWW.DENTAL.UPENN.EDUHelen Giannakopoulos, DDS, MD, AssociateProfessor; Director, Postdoctoral Oral & MaxillofacialSurgery Residency ProgramEric J. Granquist, DMD, MD, Assistant ProfessorBarry H. Hendler, DDS, MD, Associate ProfessorElliot V. Hersh, DMD, MS, PhD, ProfessorNeeraj Panchal, DDS, MD, MA, InstructorPeter D. Quinn, DMD, MD, Schoenleber Professor;Vice Dean for Professional Services, Perelman Schoolof Medicine; Senior Vice President for CPUP, Universityof Pennsylvania Health SystemRabie Shanti, DMD, MD, Assistant ProfessorDavid C. Stanton, DMD, MD, FACS, AssociateProfessorSteven Wang, DMD, MD, MPH, InstructorPart-Time FacultyAlexandre Balaci, DMD, Clinical AssociateSung-Kiang Chuang, DMD, MD, DMSc, ClinicalProfessorBruce J. Cutilli, DMD, MD, Clinical Assistant ProfessorDouglas Ditty, DMD, MD, Clinical Assistant ProfessorBrad Hersh, DMD, Clinical AssociateAnna Kornbrot, DMD, Clinical Assistant ProfessorDominic Poyle Lu, DDS, Clinical ProfessorJohn W. Mooney, DDS, Clinical Associate ProfessorChristopher Perrie, DDS, MD, Clinical AssociateDonald G. Rebhun, DMD, Clinical Assistant ProfessorJames Salman, DMD, Clinical AssociateDavid W. Wedell, DDS, Clinical Assistant Professor
FOSTERING INTERDISCIPLINARY, PATIENT-CENTERED CARE INCORPORATING THE LATEST TECHNOLOGY, RESEARCH, AND INTEGRATED CARE, THE DEPT. OF ORAL & MAXILLOFACIAL SURGERY IS MAKING PATIENTS WHOLE AGAIN ABOVE: Pre-operative and post-operative 3D-stereo-lithographic models of a patient with a benign tumo
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