Education in maxillofacial prosthetics Varoujan A. Chalian, D.D.S., M.S.D.* Indiana University School of Dentistry, Indianapolis, Ind.
A
t the Annual Session of the American College of Prosthodontists in 1973, William R. Laney projected that the role of maxillofacial prosthetics will change considerably in the next 25 years. The need for prosthodontic rehabilitation of congenital orofacial defects will greatly diminish. The need for treatment of traumatic injuries will remain generally stable. On the other hand, the maxillofacial prosthodontist will play an increasingly important part in the management of patients with malignant disease of the head and neck. The incidence of head and neck cancer has increased significantly over the past few decades. Treatment procedures have improved to such an extent that more patients are surviving for longer periods. Often there are associated psychological and socioeconomic problems. To achieve effective rehabilitation, maxillofacial prosthodontists will have greater responsibility in the total care of cancer patients. Dentists and dental laboratory technicians trained in maxillofacial prosthetics are in short supply, and they are urgently needed to staff existing cancer centers and establish new departments. It is difficult to estimate how many additional maxillofacial prosthodontists and technicians are required in the nation. However, certain indicators shed light on the subject. Congress apparently feels that present and future needs for cancer treatment will justify substantial expenditures. The National Cancer Institute (NCI) is stimulating the organization of core cancer centers, and prosthetic rehabilitation is considered to be one of the most important services. In fact, the training of 29 prosthodontists, who are now providing services, has been underwritten by NCI. In 1975 the National Institutes of Health spent 1.5 million Presented at the American Academy of Maxillofacial Prosthetics, San Diego, Calif. *Professor and Chairman, Maxillofacial Prosthetics.
0022.3913/78/
110579 + 04too.40/0
0 1978 The C. V. Mosby Co
dollars directly for the training of maxillofacial prosthodontists and technicians. Even local cancer societies are supporting maxiilofacial programs. Throughout the academic world, as well as in the realm of clinical care, maxillofaciat prosthetics is gaining acceptance as a specialty with an integral role in the total treatment team. Surgeons, radiotherapists, and other team members are demanding the services of the prosthodontist. Maxillofacial prosthodontists are being offered faculty positions in specialty departments of medical schools and even partnerships in private practices with surgeans. Those working at rehabilitation centers are acutely aware of the shortage of maxilfofacial prosthetic clinicians. Until now, almost all trained maxillofacial prosthodontists have been absorbed as staff members of training programs. In fact, a large percentage of the trained personnel are doing little or no clinical work, yet the demand far clinicians is obvious, and medical centers and dental schools are reacting to meet it. The National Cancer Institute, funded by Congress, is stimulating the increase in the training of maxillofacial prosthodontists and technicians.
INSTITUTIONAL
DESIGN
The institutional design of maxillofacial rehabilitation centers should parallel the design of medical centers. This is necessitated by the team approach to treatment, by the incidence of disease in the population base, and by geography. For effective rehabilitation, there must be cooperative efforts among all members of the team from the start and throughout the treatment. Any barrier to this cooperation, whether it be geographic or administrative, will affect the quality of the rehabilitation. As the demand for treatment increases, as treatment methods are refined, and as more clinicians become available, the design possibilities increase. It will become more feasible to establish maxillofacial prosthetic clinics in association with dental schools
THE JOURNAL OF PROSTHETIC DENTBTRY
579
CHALIAN
that are not in close proximity to a medical center. As the availability of the other team members increases, so will the opportunities for private practice. Cooperating institutions may take the opportunity to consolidate their services. However, the ideals of team treatment so necessary for most maxillofacial patients are best fulfilled by the establishment of regional maxillofacial centers, in close relation with institutions. The number and dispersal of these centers are best determined by an informed estimate of what is needed to provide optimum service to the population. The ideal administrative structure for a maxillofacial prosthetic department is to be affiliated with both a school of dentistry and a school of medicine. Although the maxillofacial prosthodontist obtains his credentials through dentistry, he should function in a semiautonomous role on an equal basis with other team members. At present, function is facilitated by longitudinal affiliation with a department of surgery. The future will see a horizontal structure, in institutions and private practice, with the prosthodontist affiliated on an equal and autonomous basis. This relationship facilitates more efficient service for all members of the team. In an age of ever-increasing specialization, and although there will always be a longitudinal component, effective function dictates a horizontal structure.
CURRICULUM DESIGN FOR THE PRUSTHODONTIST We must attract graduate students who are highly intelligent, resourceful, and well motivated. It is also imperative that maxillofacial prosthetics be emphasized on the undergraduate level. This is not only a breeding ground for future prosthodontists, but it also enables the general dentist to gain the knowledge needed to use maxillofacial prosthetic services on a referral or consultation basis. Criteria for the selection of prosthodontic trainees include references, undergraduate records, and at least equal emphasis on personal interviews. Naturally, intelligence and personality are important criteria, but motivation and resourcefulness must also be emphasized. Laney stated at the 1973 meeting of the American College of Prosthodontists: “The current philosophical approach to educating the maxillofacial prosthodontist suggests two years of participation in conventional fixed and removable prosthesis programming, with one additional year of concentrated maxillofacial experience. It is
580
not inconceivable that the three-year period will be insufficient, and a fourth year, during which the prosthodontist serves as a senior level resident with increased hospital responsibilities, could become necessary.” There is no doubt that a firm background in prosthodontics is a necessity and that the 2 plus 1 year program is a very fine approach. However, it is sometimes difficult to attract a board-eligible prosthodontist to an additional l-year training program. An alternative 3-year program is suggested in which the beginning period emphasizes conventional prosthodontics as a foundation. The trainee is gradually exposed to maxillofacial prosthetics as expertise in conventional prosthodontics is acquired. The latter stage of training emphasizes maxillofacial prosthetic rehabilitation, with fixed and removable prosthodontics being reinforced. This program may be more easily adapted to the needs and development of the individual and is not hindered by the adjustment period in the change from a 2-year program to the added l-year program. It is practical for both of these programs to exist side by side, with benefits accruing to trainees of both programs. The specialty of maxillofacial prosthetics is unique. It treats unique patients, each with unique defects. The maxillofacial prosthodontist must often call on all that his intellect, resourcefulness, and experience can offer. Clinical experience must be the nucleus of a maxillofacial prosthetic program. Just as a sound foundation is needed in constructing a house, the foundation of a maxillofacial prosthetic curriculum should be laid with primary emphasis on academic learning, but the substance of the program is the siding and rafters of practica1 experience. Academic work should be concentrated in the first year of training and never completely phased out. The academic prerequisite to clinical experience should constantly be reinforced with literature review and seminars. The student who intends to specialize in maxillofacial prosthetics should be offered these clinical experiences: (1) management of patients with intraoral and extraoral defects acquired from pathologic, traumatic, or developmental processes, as well as from congenital etiology; (2) constructing obturator resections of edentulous prostheses for maxillary maxillae; (3) constructing obturator prostheses with metal frameworks for maxillary resections of partially edentulous maxillae; (4) constructing cleft palate prostheses for palatopharyngeal inadequacies; (5)
NOVEMBER
19713
VOLUME
40
NUMBER
5
EDUCATION
IN MAXILLOFACIAL
PROSTHETICS
making removable prostheses with bar and clip attachments; (6) making surgical prostheses for maxillary and mandibular resections; (7) fabricating cranial and facial implants using different materials; (8) making occlusal acrylic resin or metal splints; (9) constructing stents for radiation treatment and reconstructive plastic surgery; (10) fabricating complete and/or removable partial dentures for radiated mouths; (11) constructing mandibular resection prostheses and/or guidance devices for partial mandibular resections; (12) making overdentunes; (13) fabricating facial prostheses (ocular, orbital, nasal, auricular, and combinations of these); (14) clinical exposure and/or participation in the clinical services of oncology (tumor board), surgery (general and plastic), radiology (diagnostic and therapeutic), clinical pathology (dermatology and cleft lip and palate), and otorhinolaryngology. The student must also develop clinical competence in the components of fixed and removable prosthodontics. His clinical education should include (1) single restorations (full crowns, partial veneer three-quarter crowns, and pinledge retainers); (2) three- and four-unit fixed partial dentures; (3) restorations and fixed partial dentures as mouth preparation for removable partial dentures (extracoronal attachments, intracoronal attachments, and bar and clip attachments); (4) complete maxillary dentures opposing class I or II removable partial dentures; and (5) complete dentures. All advanced students who wish to become diplomates know that they must be examined by the American Board of Prosthodontics to prove their clinical competence. As part of their clinical requirements, they must be capable of doing their own laboratory work. Therefore, they should supplement their clinical activities by performing all laboratory procedures. This laboratory experience can be used as a tool for clinical self-evaluation.
CURRICULUM DESIGN FOR THE LABORATORY TECHNICIAN Maxillofacial prosthetic technicians should be trained alongside of prosthodontists. This benefits both groups and facilitates later communication and cooperation. Consequently, the technician’s curriculum has many aspects in common with that of the prosthodontist. Criteria for the selection of technician trainees includes their previous technical and academic record and experience, references, and personal interviews. Intelligence, manual skills, and knowl-
THE JOURNAL
OF PROSTHETIC
DENTISTRY
edge of materials are important attributes, with an emphasis on resourcefulness and the ability to communicate with the prosthodontist on common ground. It has been suggested in some quarters that artists be recruited as technicians. A sculptor’s contribution to restoring a facial defect would be valuable. if a maxillofacial prosthetic clinic had the time, the money, and the demand to justify his training, Facial restorations make up only a small percentage of a maxillofacial prosthetic practice, with most prostheses being intraoral and constructed with conventional dental materials and techniques. In addition, it is my experience that sculpting and coloration are not the critical factors in the success of a facial prosthesis. When a facial prosthesis fails, it is generally due to the material used. Parenthetically, it is not advisable to support any facial prosthetist working outside the jurisdiction of an already established profession. A dental laboratory technician is an important part of a maxillofacial prosthetic practice. He has the knowledge and skill to perform many of the necessary technical procedures? and he has a background and a vocabulary similar to that of the prosthodontist. The employment of a sculptor in addition to a laboratory technician is dependent upon the volume of patients in need of facial prosthetic rehabilitation. If today’s demands are to be met expeditiously, without duplication of time and effort, dental laboratory technicians should be selected for maxillofacial prosthetic training. Dental laboratory technicians who have completed an accredited training program and gained some practical experience in conventional technical procedures would require approximately 1 year of maxillofacial prosthetic training. The first half of the training period should stress the academic area of material science, anatomy and physiology, and technique work with various idealized cases Later the trainee should be phased into practical maxillofacial prosthetic cases under supervision. The ability to work with a prosthodontist as an auxiliary is of the utmost importance. Inventiveness and understanding of the total treatment problem are an invaluable part of the curriculum. These can br achieved through “side-by-side” training pragrams and joint participation in treatment planning and seminars. An effective maxillofacial prosthetic training program has been outlined. However, the proper training of individuals is not in itself enough to meet the demands of the future. Our manpower must be used more efficiently. A “clearinghouse,” with list-
581
CHALIAN
ings of position opportunities and qualified personnel should be established by the Academy of Maxillofacial Prosthetics. Further investigation is necessary to determine the future needs of maxillofacial prosthetics in terms of manpower and geography. The establishment of regional rehabilitation centers in areas of need could be encouraged.
QUALITY CONTROL The goal is to promote effective training programs, efficient use of manpower, and quality rehabilitation. Since 1953, when the Academy of Maxillofacial Prosthetics was established, one of its objectives has been to gain recognition of the maxillofacial prosthodontist as a legitimate member of the health care team. In 1967 the ADA Council on Dental Education recognized the specialty, and in 1969 the specialty was accepted by the American Board of Prosthodontics. This recognition has been
an impetus for the growth of maxillofacial prosthetics with established standards of certification and legitimacy. Affiliation with these organizations establishes a system of peer review as the best system to control the quality of maxillofacial prosthetics.
CONCLUSION Organized dentistry is the source of the ethics and training in maxillofacial prosthetics. The structure of health care delivery sets the pattern of the functional role of the maxillofacial prosthodontist, who must be an equal partner in the total treatment team. A great challenge exists to meet the demands of the future. Reprint requeststo: DR. VAROUJAN A. CHALIAN INDIANA CNIVERSITV SCHOOL OF DENTISTRY INDIANAPOLIS. IND. 46202
ARTICLES TO APPEAR IN FUTURE ISSUES Antimycotic
denture adhesive in treatment of denture stomatitis
E. A. Scher, M.B., B.D.S. M.Sc., G. M. Ritchie, M.D.S., L.D.S.R.C.S.(Eng), and D. J. Flowers, M.I.Biol., F.I.M.L.S.
The efficacy of remount procedures using masticat4x-y performance test5 A. B. Sidhaye, M.D.S., and S. B. Master, B.Sc., M.D.S.
Sequential pa&a4 expansion and premaxilby infants
retiwsisn
for cl&
palate
Charles G. Stankewitz, D.D.S., Eugene E. Overton, D.D.S., James S. Brudvik, D.D.S., and Francis C. Burton, M.D.
Constructing
occlusal splints
Roberto von Krammer K., D.D.S.
582
NOVEMBER
1978
VOLUME
40
NUMBER
5
A
t the Annual Session of the American College of Prosthodontists in 1973, William R. Laney projected that the role of maxillofacial prosthetics will change considerably in the next 25 years. The need for prosthodontic rehabilitation of congenital orofacial defects will greatly diminish. The need for treatment of traumatic injuries will remain generally stable. On the other hand, the maxillofacial prosthodontist will play an increasingly important part in the management of patients with malignant disease of the head and neck. The incidence of head and neck cancer has increased significantly over the past few decades. Treatment procedures have improved to such an extent that more patients are surviving for longer periods. Often there are associated psychological and socioeconomic problems. To achieve effective rehabilitation, maxillofacial prosthodontists will have greater responsibility in the total care of cancer patients. Dentists and dental laboratory technicians trained in maxillofacial prosthetics are in short supply, and they are urgently needed to staff existing cancer centers and establish new departments. It is difficult to estimate how many additional maxillofacial prosthodontists and technicians are required in the nation. However, certain indicators shed light on the subject. Congress apparently feels that present and future needs for cancer treatment will justify substantial expenditures. The National Cancer Institute (NCI) is stimulating the organization of core cancer centers, and prosthetic rehabilitation is considered to be one of the most important services. In fact, the training of 29 prosthodontists, who are now providing services, has been underwritten by NCI. In 1975 the National Institutes of Health spent 1.5 million Presented at the American Academy of Maxillofacial Prosthetics, San Diego, Calif. *Professor and Chairman, Maxillofacial Prosthetics.
0022.3913/78/
110579 + 04too.40/0
0 1978 The C. V. Mosby Co
dollars directly for the training of maxillofacial prosthodontists and technicians. Even local cancer societies are supporting maxiilofacial programs. Throughout the academic world, as well as in the realm of clinical care, maxillofaciat prosthetics is gaining acceptance as a specialty with an integral role in the total treatment team. Surgeons, radiotherapists, and other team members are demanding the services of the prosthodontist. Maxillofacial prosthodontists are being offered faculty positions in specialty departments of medical schools and even partnerships in private practices with surgeans. Those working at rehabilitation centers are acutely aware of the shortage of maxilfofacial prosthetic clinicians. Until now, almost all trained maxillofacial prosthodontists have been absorbed as staff members of training programs. In fact, a large percentage of the trained personnel are doing little or no clinical work, yet the demand far clinicians is obvious, and medical centers and dental schools are reacting to meet it. The National Cancer Institute, funded by Congress, is stimulating the increase in the training of maxillofacial prosthodontists and technicians.
INSTITUTIONAL
DESIGN
The institutional design of maxillofacial rehabilitation centers should parallel the design of medical centers. This is necessitated by the team approach to treatment, by the incidence of disease in the population base, and by geography. For effective rehabilitation, there must be cooperative efforts among all members of the team from the start and throughout the treatment. Any barrier to this cooperation, whether it be geographic or administrative, will affect the quality of the rehabilitation. As the demand for treatment increases, as treatment methods are refined, and as more clinicians become available, the design possibilities increase. It will become more feasible to establish maxillofacial prosthetic clinics in association with dental schools
THE JOURNAL OF PROSTHETIC DENTBTRY
579
CHALIAN
that are not in close proximity to a medical center. As the availability of the other team members increases, so will the opportunities for private practice. Cooperating institutions may take the opportunity to consolidate their services. However, the ideals of team treatment so necessary for most maxillofacial patients are best fulfilled by the establishment of regional maxillofacial centers, in close relation with institutions. The number and dispersal of these centers are best determined by an informed estimate of what is needed to provide optimum service to the population. The ideal administrative structure for a maxillofacial prosthetic department is to be affiliated with both a school of dentistry and a school of medicine. Although the maxillofacial prosthodontist obtains his credentials through dentistry, he should function in a semiautonomous role on an equal basis with other team members. At present, function is facilitated by longitudinal affiliation with a department of surgery. The future will see a horizontal structure, in institutions and private practice, with the prosthodontist affiliated on an equal and autonomous basis. This relationship facilitates more efficient service for all members of the team. In an age of ever-increasing specialization, and although there will always be a longitudinal component, effective function dictates a horizontal structure.
CURRICULUM DESIGN FOR THE PRUSTHODONTIST We must attract graduate students who are highly intelligent, resourceful, and well motivated. It is also imperative that maxillofacial prosthetics be emphasized on the undergraduate level. This is not only a breeding ground for future prosthodontists, but it also enables the general dentist to gain the knowledge needed to use maxillofacial prosthetic services on a referral or consultation basis. Criteria for the selection of prosthodontic trainees include references, undergraduate records, and at least equal emphasis on personal interviews. Naturally, intelligence and personality are important criteria, but motivation and resourcefulness must also be emphasized. Laney stated at the 1973 meeting of the American College of Prosthodontists: “The current philosophical approach to educating the maxillofacial prosthodontist suggests two years of participation in conventional fixed and removable prosthesis programming, with one additional year of concentrated maxillofacial experience. It is
580
not inconceivable that the three-year period will be insufficient, and a fourth year, during which the prosthodontist serves as a senior level resident with increased hospital responsibilities, could become necessary.” There is no doubt that a firm background in prosthodontics is a necessity and that the 2 plus 1 year program is a very fine approach. However, it is sometimes difficult to attract a board-eligible prosthodontist to an additional l-year training program. An alternative 3-year program is suggested in which the beginning period emphasizes conventional prosthodontics as a foundation. The trainee is gradually exposed to maxillofacial prosthetics as expertise in conventional prosthodontics is acquired. The latter stage of training emphasizes maxillofacial prosthetic rehabilitation, with fixed and removable prosthodontics being reinforced. This program may be more easily adapted to the needs and development of the individual and is not hindered by the adjustment period in the change from a 2-year program to the added l-year program. It is practical for both of these programs to exist side by side, with benefits accruing to trainees of both programs. The specialty of maxillofacial prosthetics is unique. It treats unique patients, each with unique defects. The maxillofacial prosthodontist must often call on all that his intellect, resourcefulness, and experience can offer. Clinical experience must be the nucleus of a maxillofacial prosthetic program. Just as a sound foundation is needed in constructing a house, the foundation of a maxillofacial prosthetic curriculum should be laid with primary emphasis on academic learning, but the substance of the program is the siding and rafters of practica1 experience. Academic work should be concentrated in the first year of training and never completely phased out. The academic prerequisite to clinical experience should constantly be reinforced with literature review and seminars. The student who intends to specialize in maxillofacial prosthetics should be offered these clinical experiences: (1) management of patients with intraoral and extraoral defects acquired from pathologic, traumatic, or developmental processes, as well as from congenital etiology; (2) constructing obturator resections of edentulous prostheses for maxillary maxillae; (3) constructing obturator prostheses with metal frameworks for maxillary resections of partially edentulous maxillae; (4) constructing cleft palate prostheses for palatopharyngeal inadequacies; (5)
NOVEMBER
19713
VOLUME
40
NUMBER
5
EDUCATION
IN MAXILLOFACIAL
PROSTHETICS
making removable prostheses with bar and clip attachments; (6) making surgical prostheses for maxillary and mandibular resections; (7) fabricating cranial and facial implants using different materials; (8) making occlusal acrylic resin or metal splints; (9) constructing stents for radiation treatment and reconstructive plastic surgery; (10) fabricating complete and/or removable partial dentures for radiated mouths; (11) constructing mandibular resection prostheses and/or guidance devices for partial mandibular resections; (12) making overdentunes; (13) fabricating facial prostheses (ocular, orbital, nasal, auricular, and combinations of these); (14) clinical exposure and/or participation in the clinical services of oncology (tumor board), surgery (general and plastic), radiology (diagnostic and therapeutic), clinical pathology (dermatology and cleft lip and palate), and otorhinolaryngology. The student must also develop clinical competence in the components of fixed and removable prosthodontics. His clinical education should include (1) single restorations (full crowns, partial veneer three-quarter crowns, and pinledge retainers); (2) three- and four-unit fixed partial dentures; (3) restorations and fixed partial dentures as mouth preparation for removable partial dentures (extracoronal attachments, intracoronal attachments, and bar and clip attachments); (4) complete maxillary dentures opposing class I or II removable partial dentures; and (5) complete dentures. All advanced students who wish to become diplomates know that they must be examined by the American Board of Prosthodontics to prove their clinical competence. As part of their clinical requirements, they must be capable of doing their own laboratory work. Therefore, they should supplement their clinical activities by performing all laboratory procedures. This laboratory experience can be used as a tool for clinical self-evaluation.
CURRICULUM DESIGN FOR THE LABORATORY TECHNICIAN Maxillofacial prosthetic technicians should be trained alongside of prosthodontists. This benefits both groups and facilitates later communication and cooperation. Consequently, the technician’s curriculum has many aspects in common with that of the prosthodontist. Criteria for the selection of technician trainees includes their previous technical and academic record and experience, references, and personal interviews. Intelligence, manual skills, and knowl-
THE JOURNAL
OF PROSTHETIC
DENTISTRY
edge of materials are important attributes, with an emphasis on resourcefulness and the ability to communicate with the prosthodontist on common ground. It has been suggested in some quarters that artists be recruited as technicians. A sculptor’s contribution to restoring a facial defect would be valuable. if a maxillofacial prosthetic clinic had the time, the money, and the demand to justify his training, Facial restorations make up only a small percentage of a maxillofacial prosthetic practice, with most prostheses being intraoral and constructed with conventional dental materials and techniques. In addition, it is my experience that sculpting and coloration are not the critical factors in the success of a facial prosthesis. When a facial prosthesis fails, it is generally due to the material used. Parenthetically, it is not advisable to support any facial prosthetist working outside the jurisdiction of an already established profession. A dental laboratory technician is an important part of a maxillofacial prosthetic practice. He has the knowledge and skill to perform many of the necessary technical procedures? and he has a background and a vocabulary similar to that of the prosthodontist. The employment of a sculptor in addition to a laboratory technician is dependent upon the volume of patients in need of facial prosthetic rehabilitation. If today’s demands are to be met expeditiously, without duplication of time and effort, dental laboratory technicians should be selected for maxillofacial prosthetic training. Dental laboratory technicians who have completed an accredited training program and gained some practical experience in conventional technical procedures would require approximately 1 year of maxillofacial prosthetic training. The first half of the training period should stress the academic area of material science, anatomy and physiology, and technique work with various idealized cases Later the trainee should be phased into practical maxillofacial prosthetic cases under supervision. The ability to work with a prosthodontist as an auxiliary is of the utmost importance. Inventiveness and understanding of the total treatment problem are an invaluable part of the curriculum. These can br achieved through “side-by-side” training pragrams and joint participation in treatment planning and seminars. An effective maxillofacial prosthetic training program has been outlined. However, the proper training of individuals is not in itself enough to meet the demands of the future. Our manpower must be used more efficiently. A “clearinghouse,” with list-
581
CHALIAN
ings of position opportunities and qualified personnel should be established by the Academy of Maxillofacial Prosthetics. Further investigation is necessary to determine the future needs of maxillofacial prosthetics in terms of manpower and geography. The establishment of regional rehabilitation centers in areas of need could be encouraged.
QUALITY CONTROL The goal is to promote effective training programs, efficient use of manpower, and quality rehabilitation. Since 1953, when the Academy of Maxillofacial Prosthetics was established, one of its objectives has been to gain recognition of the maxillofacial prosthodontist as a legitimate member of the health care team. In 1967 the ADA Council on Dental Education recognized the specialty, and in 1969 the specialty was accepted by the American Board of Prosthodontics. This recognition has been
an impetus for the growth of maxillofacial prosthetics with established standards of certification and legitimacy. Affiliation with these organizations establishes a system of peer review as the best system to control the quality of maxillofacial prosthetics.
CONCLUSION Organized dentistry is the source of the ethics and training in maxillofacial prosthetics. The structure of health care delivery sets the pattern of the functional role of the maxillofacial prosthodontist, who must be an equal partner in the total treatment team. A great challenge exists to meet the demands of the future. Reprint requeststo: DR. VAROUJAN A. CHALIAN INDIANA CNIVERSITV SCHOOL OF DENTISTRY INDIANAPOLIS. IND. 46202
ARTICLES TO APPEAR IN FUTURE ISSUES Antimycotic
denture adhesive in treatment of denture stomatitis
E. A. Scher, M.B., B.D.S. M.Sc., G. M. Ritchie, M.D.S., L.D.S.R.C.S.(Eng), and D. J. Flowers, M.I.Biol., F.I.M.L.S.
The efficacy of remount procedures using masticat4x-y performance test5 A. B. Sidhaye, M.D.S., and S. B. Master, B.Sc., M.D.S.
Sequential pa&a4 expansion and premaxilby infants
retiwsisn
for cl&
palate
Charles G. Stankewitz, D.D.S., Eugene E. Overton, D.D.S., James S. Brudvik, D.D.S., and Francis C. Burton, M.D.
Constructing
occlusal splints
Roberto von Krammer K., D.D.S.
582
NOVEMBER
1978
VOLUME
40
NUMBER
5
