Haiti » 'Frontier dentistry' making lives whole

Last August, Jefferson University Hospital surgeons removed a Haitian man's diseased lower jaw, then reconstructed it using bone from his left leg.

The $100,000 worth of medical care, donated by Jefferson, liberated Daniel Smith, 30, from a noncancerous but life-threatening, disfiguring jaw tumor.

The only downside to his transformation, chronicled in The Inquirer, was the lack of lower teeth.

His doctors had no way to firmly attach ordinary dentures to his pseudo gums, made of a flap of connective tissue and skin from his leg. He needed dental implants - artificial tooth roots - and state-of-the-art restorative dentistry. That would cost at least $30,000, an unimaginable sum for Smith, a vocational student who lives with his parents in a small Haitian town.

Ultimately, he got new choppers, thanks to another wave of generosity from Jefferson, the American families who hosted him, and Center City prosthodontist Louis Marion.

Smith's happy ending shows how far dentistry has come. Now, even people who lose all natural dental structures to cancer, facial trauma, or periodontal disease can be made whole, with the ability to eat, speak - and look - the way they used to.

"Implant dentistry is now pretty standard treatment with set protocols," Marion said. "But Daniel's type of craniofacial surgery with prosthodontics is pushing the envelope - frontier dentistry."

The discovery that made dental implants viable was accidental.

In 1952, to study bone healing, Swedish surgeon P.I. Branemark put titanium-covered optical devices in rabbits' bones. When he tried to remove the gadgets, he couldn't. The titanium and bone had fused, a marvel he termed "osseointegration."

Today, three million Americans have implants that anchor fake teeth, says the American Academy of Implant Dentistry.

In the usual two-stage procedure, a hole is drilled in the jaw and a half-inch-long, screw-shaped titanium post is inserted just below the gum line. The implant is topped with a changeable cap called an abutment.

The gum heals over the implant, which osseointegrates with the jaw in about four months. Then the patient has minor surgery to remove the overlying gum and expose the head of the implant.

The final abutment protrudes just above the gum, acting as a junction between the implant and the tooth or "bridge" of teeth.

Though ingenious, the system lacks the ligament that wraps around the natural root, acting as a shock absorber during chewing. Still, the long-term success rate of implants is above 95 percent.

Unfortunately, Marion said, insurance plans generally don't cover implant dentistry - even for cancer patients.

Smith, a lanky, soft-spoken man, is often literally wide-eyed at Americans' affluence and generosity.

His good fortune was the work of a lengthy list of individuals and groups dedicated to helping Haiti, starting with the Haitian Connection Network, a nonprofit online school based in Ephrata, Pa., through which he is working toward a computer-science degree in his impoverished homeland.

After Smith's life-changing reconstructive surgery, he was grateful beyond words. He considered his lower teeth - splayed and decayed - a manageable loss.

But Kim Myers of Zionsville, and her sister, Brenda Alburger of Hatfield, were disappointed. Their families gave Smith room, board, transportation - and loving care - during his U.S. sojourn.

In October, before Smith flew home, Myers appealed to Robert Diecidue, the surgeon who led Smith's reconstruction. What would it take to get him teeth? she asked.

The resulting plan: Diecidue's team would donate the cost of placing four implants in Smith's rebuilt jaw before his return to Haiti. Marion, a colleague of Diecidue's, would design and fit the dental bridge free of charge when Smith returned to the United States in five months.

And the sisters, with the help of A Child's Refuge in Fayetteville, Pa., would raise $4,000 to pay the dental lab that would fabricate the final prosthesis.

After Smith returned to the United States in April - using Myers' frequent-flier miles - the biggest challenge proved to be the toughness of the pseudo gum tissue that had been made of fascia and skin grafted from his leg.

Jefferson surgeons exposed Smith's four implants by removing bits of gum tissue, only to have it regrow within days over the two implants on the left side of his jaw, which were a tenth of an inch deeper than on the right. Temporary "healing" abutments designed to adapt the gum tissue to form a cuff did not work on the left implants.

"The leg tissue is doing what it was originally supposed to do - heal the wounds," Marion said in his office suite at 1500 Locust St.

Before that could happen again, Marion saw Smith on July 19, the day after his third gum-removal surgery. Marion was determined to proceed with the next step - making the rubbery impressions of Smith's teeth that would be a model for his prosthesis.

It wasn't easy. Raw, swollen gum tissue obscured the left implants. Marion struggled to unscrew the healing abutments and screw in taller "impression copings" to precisely mark the implants' location in the impression.

With the help of assistants Alexandra Pileggi and Paige Davis (and ample lidocaine for Smith), Marion succeeded.

Perhaps the worst part for the patient was sitting with a mouthful of purple goo. As legions of dental patients know, it takes about three minutes for the goo, alginate, to firm up enough to capture an impression.

"An eternity," Pileggi said, patting Smith's shoulder.

A week later, Marion spent more than four hours installing Smith's bridge, a set of pearly acrylic teeth and pink acrylic gums. The rigid prosthesis fit on top of his rebuilt jaw and attached to the implants with four screws inserted through tiny holes in the teeth.

The gum over the left implants still needed adjustment, so Marion used an electric coagulator to trim, cauterize and sculpt it.

On hand was technician Yakov Dvorkin from the Colonial Dental Lab in West Berlin, the company that fabricated the prosthesis.

Marion and Dvorkin agreed that when Smith bit down, one spot was not quite right. In a corrective measure that looked to the untrained eye like destruction, Dvorkin cut out a tooth-wide segment, then they used instant-hardening acrylic compounds to reconnect the bridge and make a new, smaller tooth.

Despite all this effort, the prosthesis was "temporary." The final version, which Smith will get later this month, will have an ultra-durable frame made of gold and palladium.

Smith's adjustment to his new ivories has been smooth. His upper teeth ached for a day until they got used to the renewed wonder of chewing. After six days, Smith - who once kept his chin lowered to try to conceal his bulging tumor - returned to Marion, saying he felt excited and confident.

Even though running water is a luxury in Haiti, Smith promised to brush his teeth and clean under his acrylic gums with a special floss.

"What do you see in the mirror now?" Alburger asked him.

He smiled. "How completely changed I am."

> Inquirer.com

For a treatment slide show, from Daniel Smith's first visit to his last, go to www.inquirer.com/health_science

http://articles.philly.com/2013-08-11/ne...dental-implants