Tuesday, April 26, 2011

Making a Difference: Dr. Andrew J. Ponichtera

"You know, it’s really kind of in between everything,” says Dr. Andrew J. Ponichtera. He’s sitting in his dental office in Weatogue, Connecticut, explaining his specialty, maxillofacial rehabilitation. “It’s a little bit being an artist – it’s a little bit being a dentist – it’s a little bit being a sculptor – it’s a little bit of everything. It’s a little bit playing with models.” He laughs gently at himself, then grows serious. “But the thing is, you really do get to provide a service a service that really is very satisfactory – satisfactory for both you and the patient.”

More than satisfactory, really. For people with some type of impairment – a cleft palate, a missing ear or nose – maxillofacial rehabilitation means the difference between feeling comfortable about going out in public and not. It’s that simple. And that crucial.

Ponichtera came to the field by a fairly straightforward route. He’d always been “a little bit mechanically inclined and liked to play with models and stuff like that.” In college, he hung out with two of his cousins: a dentist and a medical student who eventually became a pulmonologist. Not quite sure what he wanted to do, he began exploring their chosen fields. He quickly realized that he wasn’t cut out for pulmonology. Seeing “people that are really, really sick” bothered him, he admitted. He “couldn’t tolerate that emotionally. I just would go home and feel like crying.” Dentistry, on the other hand, “was nice – you got to do a lot of interesting things.” Plus, it appealed to that mechanical side of his nature -- his inner engineer, if you will. “So it became a natural extension, and I decided to go ahead and do that.”

He graduated from dental school in 1977 and started his residency at Sinai Hospital in Detroit. There he met his first maxillofacial prosthetist, a man who was doing “all the interesting things that I really liked to do.” The prosthetist let the young resident spend time with him while he worked with kids with cleft palates or with cancer patients who were missing eyes, ears, noses, or parts of jaws. And Ponichtera, who’d found pulmonology so difficult to handle, had no trouble dealing with people who were disfigured in some way. Here, at least, he could do something, and he “thought that was really cool.” But he wasn’t 100% sure about it as a career choice at that point and ended up going into dental practice instead.

After a couple of years “doing mundane dentistry -- doing fillings and seeing lots of people,” however, Ponichtera was ready to try something different. He got into a three-year program at the Mayo Clinic, one of the few facilities that offered residencies in maxillofacial prosthetics then. “We spent lots of time with plastic surgeons [and with] ear-nose-and-throat guys,” he recalls. “We spent almost six months being residents with those guys. It was interesting, rewarding…a specialty where patients really need your help. So it goes from seeing kids with cleft palates and speech problems to kids with craniofacial dystosis [morphic facial growth, Elephant Man’s Disease being one form] that are missing ears, cancer patients, and trauma patients.”

Ponichtera eventually made his way to the University of Connecticut Health Center in Farmington, where he worked for awhile as part of the craniofacial team for kids. Now working out of his Weatogue office, he does more with “patients that are either missing ears or parts of their face and adults with cancer.” But he doesn’t do it surgically – he does it “with plastic and so-called ‘pieces.’” For the college student who “loved working with putty and being a sculptor, it’s a natural transition. I really like it. It’s a lot of fun.”

There’s more to it than that, naturally. Compassion is key, and Ponichtera has more than most people.  You need, he says, “a certain mentality to see people -- some of whom are grossly disfigured, some of whom really smell” because of necrotic tissue. So it’s a matter of seeing beyond all that? I ask. “You have to do beyond all that,” he counters quietly. “Your staff has to be attentive to that. You can’t yell, ‘Oh, God!’ You just have to accept them as being normal, and everybody here is good at that.” The staff gets involved in other ways, too: “We’ve made some really interesting prostheses, and they end up stitching head bands together to help hold on a facial prosthesis.”

He touches briefly on Frances Derwent Wood, the British sculptor who devised electroplated masks for disfigured soldiers during World War I. This was where maxillofacial prosthetics really started, Ponichtera insists – with Wood and others trying to help men “that wouldn’t have survived before. A lot of traumatic injuries, different weapons….It really came by default into the hands of dentistry.” Now the field is “an acknowledged specialty or sub-specialty of dentistry that’s been around quite awhile. But the bulk of it came in World War I and World War II – a lot of changes, a lot of new techniques.”

Of course, with implants and more sophisticated technology, that picture is changing once again. There’s even talk about doing much of the work via CAD/CAM software. And now, Ponichtera explains, “almost all of the oral surgeons, almost all of the programs are gonna be M. D. programs. They have much more training in facial and plastic surgery, and they’re getting out of the role of just taking out teeth. But there’s still a select population that can’t be treated surgically. And that’s where I come in.”

A lot of kids missing ears get sent over from Connecticut Children’s Medical Center (CCMC) in Hartford, for instance. He’ll make a diagnostic wax-up or guide for where the implants need to be; later, after Dr. Richard Bevilaequa at CCMC has surgically placed the screw, Ponichtera will “attach a silicone ear to it. Clips in – clips off. We’ve done noses that way – clip in and clip off – and, well, you don’t have to worry about it. It stays on.” In the past, they would’ve had to glue the prostheses on.

Sometimes his creativity really gets a work-out, Ponichtera admits. They’ve had a couple of people come in “who have been missing almost half their face, and you really can’t put implants in because” – there’s a long, thoughtful but matter-of-fact pause – “they’re kinda at the end stage of life. But you can make them a prosthesis, and they become a little more socially acceptable. And that’s kinda cool.”

He shows me a model. “The ear is over here,” he says. “We make it out of wax so that we can basically boil it out.” That leaves him with a model to put the silicone in; the silicone then cures with a little bit of heat. He brings out more forms: one for a patient without an eye an another for a cancer patient missing part of a jaw. (The latter has an obturator for closing the the palate's opening.) He keeps the individual molds in case the patients ever need replacements parts. “I mean, I could make another ear for this patient without his being here. And I have a record of what colors they use….We used to mix up all our own colors.” He laughs. “Like art class. Now they have kits that are available. But I still have my own colors that I like to use. Just gets you a little bit better customization.”

In fact, Ponichtera really prefers doing the whole process himself. He gets a stronger sense of what works for the patient that way. And he’s not above bringing his work home with him. “My wife gets a little bit upset with me at times because” – he chuckles – “I’ll be doing this in the basement for a few hours.”

So, what would Derwent Wood say to it all? “He’d be amazed at how much it had changed,” Ponichtera concedes. “But the principles haven’t changed.” He himself appreciates the technological advancements but still leans toward the hand-crafted. “And that’s what I get out of it,” he says. “It’s like you put your little heart and soul in the whole thing, and it’s yours. And I think there’s more value in it than if it’s just done by computer or manufactured."