On any given day, at any given time, NYU’s oral and maxillofacial surgery program is delivering care, making discoveries and impacting lives. It’s the place people come to when their conditions are especially severe and complex, calling for the most sophisticated, innovative treatment approaches.
An integral part of both the New York University College of Dentistry and the NYU Medical Center, the program draws on a unique set of assets, including operating privileges at both NYU’s Tisch Hospital and the legendary Bellevue Hospital Center. Above all, the program is defined by the matchless skills of NYU College of Dentistry oral and maxillofacial surgeons, who are leaders in developing newer surgical techniques for treating diseases and caring for patients. Their innovation and experience unite with compassion and understanding to provide patients with the best care possible, particularly in the areas of trauma and reconstruction, sleep apnea, salivary gland disease, oral cancer and pediatric cleft lip and palate. "Patients are our top priority," says Dr. Robert Glickman, Professor and Chair of the Mecca Department of Oral and Maxillofacial Surgery, "and that focus colors everything we do."
In the pages that follow, we offer a glimpse at the lives of people whose stories will touch your heart and at the highly skilled faculty who are making a difference in their lives.
Endoscopic Surgery for Salivary Gland Disease
NYUCD is at the forefront of minimally invasive techniques in oral and maxillofacial surgery and is the only institution in the New York area and one of only a handful in the nation to perform minimally invasive diagnosis and treatment for sialoadenitis, or salivary gland inflammation.
Sialoadenitis, which constitutes about half of all major salivary gland diseases, occurs when saliva cannot exit the ducts, causing pain and swelling that can be particularly acute when a patient eats. Sialoadenitis can be caused by scar tissue formation, foreign bodies and salivary gland stones (sialolithiasis).
Michael Turner, DDS, MD, an Assistant Professor of Oral and Maxillofacial Surgery, is one of only six surgeons in the United States who performs this kind of surgery.
Dr. Turner recalls the case of one patient, a 56year old woman, whose sialoadenitis began developing after a childhood infection left scare tissue obstructing her ducts. With her condition worsening and surgeons advising her to have the gland removed, the woman’s hopes for a recovery had faded until she was referred to NYU for treatment by Dr. Turner.
In a procedure known as a sialoendoscopy, Dr. Turner used a specially designed, FDAapproved endoscope to pinpoint the woman’s inflammation and then applied hydrostatic pressure through a balloon to break up the scar tissue obstructing her ducts. Within two weeks, she regained her ability to taste without the scarring and prolonged recovery common to patients who have had glands removed.
"The beauty of the minimally invasive approach," says Dr. Turner, "is that we can isolate our optimal entry site, and then use the endoscope to plan the ideal trajectory to reach the gland. We know exactly where the tip of our instrument is at all times within one to two millimeters. This minimizes disruption to surrounding tissue and improves chances of a full and speedy recovery.
"This is a new paradigm for treating salivary gland disease," says Dr. Turner, who notes that it may also lead to new technology and treatment for other diseases. "What comes out of the salivary gland is representative of what is in other areas of the body. NYUCD is in the vanguard of this research, which we are conducting in collaboration with some of the nation’s leading scientists in patientbased molecular diagnostics and technologies, including Dr. David Wong at UCLA, Dr. Bruce Baum at the NIH, and Dr. Daniel Malamud at NYUCD."
Pediatric Cleft Lip and Cleft Palate Treatment
NYUCD is a leader in offering the full range of pediatric oral and maxillofacial surgery care. Key to this program is Vasiliki Karlis, DMD, MD, an Associate Professor of Oral and Maxillofacial Surgery and the Director of NYU’s Advanced Education Program in Oral and Maxillofacial Surgery, who has dedicated herself to restoring young jaws ravaged by cleft lip and cleft palate and to the management of the pediatric patient.
Dr. Karlis performs major jaw surgery at Bellevue Hospital Center and at the NYU Medical Center, and is the Director of the Outpatient Pediatric Anesthesia Program at NYUCD. Many of the youngsters Dr. Karlis treats are immigrants, like the two young cousins born in the Dominican Republic who were referred to her through NYUCD’s orthodontics program.
The 12year old cousins were born with cleft lip and palate, one unilateral and one bilateral. Cleft palate is a birth defect of the mouth. It occurs when the palate does not grow as expected during fetal development. This leaves an opening, or cleft, in the roof of the mouth that may go through to the nasal cavity. Cleft lip is one or more splits in the upper lip.
These can range from a small indentation to a split in the lip that may extend up into one or both nostrils. Both conditions can cause a host of related problems, including eating problems, ear infection and hearing loss, speech problems, and dental problems, such as missing, extra, malformed or displaced teeth requiring dental and orthodontic treatment.
Both girls originally had cleft lip surgery in the Dominican Republic. As they grew older they began experiencing breathing and eating problems. To enable them to function better, Dr. Karlis grafted bone from their hips and put it into their jaws. They will need additional lip surgeries later to achieve better aesthetics, but for now, they have the foundation in place that will allow their teeth to erupt properly into their mouths. With their family’s meager financial resources, the girls would not have found the expert care they received were it not for the NYU program.
In addition to her work at NYU, Dr. Karlis also organizes global outreach visits to parts of the world with the highest numbers of cleft palates. Foremost among these is Mexico, where a combination of genetic and environmental factors is believed to cause a high incidence of cleft lip and palate deformities, creating a demand for treatment far exceeding available resources.
For over 15 years, Dr. Karlis and her oral and maxillofacial surgery residents have traveled each summer to underserved areas in Mexico to provide care for cleft lip and palate patients ranging in age from newborns to people in their twenties, and to train Mexican dentists in newer treatment methods. "I see these trips as an important part of our obligation to improve health globally, both by providing care and by training the next generation of trainers," she says.
Newer Approaches to Treating Sleep Apnea
"There are certain areas in which dentists can make a lifealtering difference," says Kenneth Fleisher, DDS, an Assistant Professor of Oral and Maxillofacial Surgery. Obstructive sleep apnea is one of these areas."
Sleep apnea is as big a problem in the U.S. as diabetes and asthma and is a significant contributing factor in heart disease. Obstructive sleep apnea occurs when a portion of the upper airway becomes obstructed by the tongue, tonsils, soft palate and/or muscles along the throat, causing breathing during sleep to stop for 10 seconds or longer. Not only can their subsequent daytime drowsiness jeopardize their own and others’ safety, but such patients may also develop chronic, potentially fatal, health problems, including hypertension caused by low blood oxygen levels during sleep. All told, the cost of untreated sleep apnea in the United States is estimated at $3.4 billion, with at least one in 15 adults believed to be suffering from the condition.
For patients willing to wear nighttime breathing masks, which improve breathing, their conditions can be successfully managed 100 percent of the time. However, approximately 50 percent of patients who suffer from obstructive sleep apnea cannot tolerate these breathing masks.
Traditional surgical approaches do not always yield good, longterm results, largely because they do not address all areas of obstruction. Contemporary techniques focus on enlarging the entire upper airway, including the throat, tongue, and palate. But if the tongue or jaw is moved too far forward, it can result in an unattractive appearance. Moreover, with most sleep apnea patients, the upper airway, where the obstruction occurs, is related to the structure of the jaws, and only oral and maxillofacial surgeons deal specifically with abnormalities of the hard and soft tissues of the jaw.
Two years ago Dr. Fleisher began developing a treatment protocol that combines a more modest surgical approach with a tongue suspension, a process of creating additional space around the upper airway to compensate for the limited effects of the more modest jaw advancement procedure. And thanks to phenomenal advances in imaging technology, Dr. Fleisher has been able to increase the predictability of this technique and significantly reduce the risk of complications, such as jaw fracture or damage to teeth roots.
Dr. Fleisher uses an instrument called a cone beam computer tomography scanner, which eliminates the distortion commonly seen in panoramic Xrays and provides a more accurate depiction of bone levels in the jaw and mouth. He has used it to perform the combined procedure on 15 patients to date and all have experienced a significant decline in their sleep apnea symptoms, with no negative side effects in terms of appearance.
"Combining tongue suspension and jaw advancement," Dr. Fleisher says, "is one example of how oral and maxillofacial surgeons individualize treatment based on location of the obstruction, facial bone dimensions and severity of the sleep apnea. As technology advances further, surgeons will continue to develop newer procedures tailored to patients’ specific needs."
The Best in Cancer Care
David Hirsch, DDS, MD, a Clinical Assistant Professor of Oral and Maxillofacial Surgery, specializes in all aspects of head and neck cancer, and has a particularly keen interest in salivary gland cancer.
"Because more and more dentists and oral surgeons are doing oral cancer screenings," he says, "I typically see patients earlier in their illness than they might have been seen in the past. This increases the odds for early diagnosis, effective treatment, cure and rehabilitation. In fact, about 30 percent of the oral cancer cases I see come from NYUCD referrals of patients with squamous cell arcinoma. Salivary gland cancer is a little different because it manifests itself with a lump, typically a swelling of the hard palate, rather than the thin, flat cells typical of squamous cell carcinoma. Most salivary gland patients are referred by oral surgeons.
"When I’m able to see stage 1 and stage 2 oral cancers, the fiveyear survival rate is between 70 and 90 percent," says Dr. Hirsch, "whereas stage 3 patient survival rates drop below 60 percent." In addition to better survival rates, detecting cancer early, before the tumor has a chance to metastasize, generally means less surgery and better rehabilitation outcomes.
Recently Dr. Hirsch has started seeing oral cancer among young people. "Whereas oral cancer traditionally has been known as a disease of the elderly," he says, "I have seen it—especially cancer of the tongue—occurring more and more among women of childbearing age, with none of the classic risk factors. This may be the beginning of a trend, which certainly requires close observation."
One of Dr. Hirsch’s patients, a 32year old woman, was three months pregnant when she discovered an ulcer on her tongue that wasn’t healing. Unfortunately, her obstetrician told her not to worry about it until after she gave birth, which turned out to be exactly the wrong advice. About four months after her baby was born, the ulcer still had not healed. Finally, she saw an oral surgeon who biopsied the lesion and diagnosed oral cancer. Then she was referred to Dr. Hirsch, who performed a partial glossotomy and fullneck dissection and sent her home two days later. While her prognosis is good, she does require radiation therapy because her tumor showed some aggressive characteristics, which tends to occur in younger people. This means she will require more radiation than an older patient, making her more susceptible to its risks, including the possibility of developing a secondary carcinoma. Still, she’s one of the lucky ones.
Another patient, a 46year old woman, was not so lucky. By the time she saw Dr. Hirsch, her oral cancer was so advanced that it required her to lose half her tongue and to stay in the hospital for two weeks. "We have to be extremely vigilant in screening patients," says Dr. Hirsch, "and extremely aggressive in treating them."
That aggressive approach often calls for Dr. Hirsch to excise large, composite blocks of tissue, which include mucosa, muscle, and bone, followed by a reconstruction often using microvascular free tissue transfer. This process requires taking tissues from other parts of the body along with their blood supply and bringing them up to the oral cavity in order to reconstruct it. This is done because there’s not a lot of tissue that can be taken from the oral cavity and the head and neck region.
Dr. Hirsch might take skin from the forearm, along with a portion of the radial bone and radial artery, and bring it up to the oral cavity to rebuild the tongue. The vessels that he takes with it get plugged into the vessels in the neck, allowing the tissue to live on its own. This is important because many oral and head and neck cancer patients also receive radiation and when you reconstruct with tissue that has its own blood supply, it resists the deleterious effects of the radiation. Similarly, the reconstruction might require tissue from the fibula, the scapula, the hip or the abdominal muscles, all with their own blood supply.
"What’s really key," says Dr. Hirsch, "is that we halt the patient’s risk for oral cancer progression. And because we have more treatment options today than ever before, we can offer our patients a better future."
Jaw Orthopedics: A New Paradigm for TMD Treatment
According to Dr. Glickman, "A new paradigm in the treatment of temporomandibular joint disease is emerging, one in which the guiding principle is recovery."
Temporomandibular joint disease (TMD) is an umbrella term referring to problems causing acute or chronic inflammation of the temporomandibular joint, which connects the lower jaw to the skull. The temporomandibular joint is susceptible to all the conditions that affect other joints in the body, including ankylosis, arthritis, trauma, dislocations, developmental abnormalities, and neoplasia. Millions of people are afflicted with TMD, and most have some type of repetitive injury occurring in the joint.
Although treatment for TMD is often similar to treatment for other joints in the body, some variations exist. Unlike every other joint in the body, in the temporomandibular joint, one side is directly connected to the other side. As a joint that not only hinges, but also slides, it places a lot of stress on the opposite joint, resulting in pain and/or dysfunction. For example, people suffering from TMD have difficulty opening their mouths to eat, which can vitally impact health as well as lifestyle. In fact, the disorder and resulting dysfunction can result in such significant chronic pain, impairment, stress and anxiety, that many people are no longer able to function.
In the past, dentists treated TMD pain as an occlusion issue, generally with uneven results, and pain specialists treated it with pain medication, which provided only temporary relief. But recent advances in microsurgical techniques and improvements in neuroimaging have allowed oral and maxillofacial surgeons greater access in reaching through the face and neck to the base of the skull in order to properly evaluate the articulation of the temporomandibular joint. The objective is to distinguish between mechanical determinants of pain, or pain that is distinctly joint related, such as from repetitive motion types of injuries and their effects, and pain that has contributing factors from other areas of the head and neck. The resulting treatment approach is both multidisciplinary and multimodal, because oral surgeons can determine precisely where the pain is coming from in order to treat the mechanical component, or jaw orthopedic component, and the pain specialist can focus on the pain.
One of Dr. Glickman’s patients, a 50year old woman from upstate New York, recently benefited greatly from this newer approach. The woman suffers from osteolitic, or degenerative, joint disease. In the 1980s, when her pain began, she had what at the time looked like very promising therapy for the early signs of her condition. A deteriorating disk in her jaw was removed surgically and replaced with an artificial disk, a Teflon proplast substance. But her body rejected the implant, initiating a severe foreign body reaction, which exacerbated her pain. She subsequently had several additional procedures to remove the disk and manage the foreign body reaction, but her pain never completely subsided. Eventually, after four unsatisfactory surgeries, she was referred by her oral surgeon to Dr. Glickman.
Until recently, her only option was removal of the joint without reconstruction. But the past several years have seen a refinement not only of imaging technologies but also of reconstruction materials that has made the kind of simultaneous surgery and reconstruction that Dr. Glickman performs the standard of care for adults.
To create a prosthesis that would fit her perfectly, Dr. Glickman and his team used the latest CAT scan imaging. From that imaging, a very accurate stereolithographic model was constructed, which enabled the construction of a joint prosthesis which reduced surgical time and increased reliability of fit. In the past, the surgery would have required two or three procedures; today it is all done in one surgery, which Dr. Glickman performed at Tisch Hospital. Her joint prosthesis, made of titanium and other synthetic materials that prevent excessive wear on the bony structures, has an estimated lifespan of between 20 and 30 years. Interviewed just weeks after her surgery, Dr. Glickman’s patient described herself as "delighted" with the results. In addition to followup visits with Dr. Glickman, she is also seeing a pain management specialist at Tisch Hospital, Dr. John Delfino, an oral and maxillofacial surgeon in Dr. Glickman’s group, who subspecializes in pain management of the head and neck.
"At NYU," says Dr. Glickman, "We are unique in having access both to unparalleled surgical resources and to the newest pain treatment strategies, including the most advanced technology. Through referrals from the NYU College of Dentistry, as well as from general dentists and ENT surgeons, we also see more challenging patients than many other programs in the nation. Thanks to all these assets, and especially to our great oral and maxillofacial surgical team, we are able to provide cuttingedge diagnosis and seamless treatment for TMD patients, who can now look forward to pursuing a painfree life."