Bonner, E. M.

Cleaton-Jones, P.

Wolfaardt, J. F.

English

Wits Institutional Repository on DSPACE

Journal of the Dental Association of South Africa 41,181-184
The need for and value of a maxillofacial prosthodontic service 
in the Witwatersrand-Vaal area: part II: A survey of patients 
who required maxillofacial prosthodontic treatment
E.M. Bonner*, J.F. Wolfaardt* and P. Cleaton-Jones**
*Department of Prosthetic Dentistry, University of the Witwatersrand, Johannesburg and **M.R.C./University of the 
Witwatersrand, Dental Research Institute, Johannesburg.
Keywords: Maxillofacial prosthodontic service, patient needs, establishing o f service
SUMMARY
The present study was undertaken to help plan future 
needs o f patients with head and neck defects in a maxillo­
facial prosthodontic service for the Witwatersrand-Vaal 
area. A  questionnaire was sent to 100 patients who had 
been treated in the Maxillofacial Prosthetic Service o f the 
Department o f Prosthetic Dentistry o f the Oral and Den­
tal Teaching Hospital o f the Witwatersrand, Johannes­
burg. The major problem confronting the patients was the 
hardship endured while being placed on the waiting list 
prior to the initiation o f treatment. The present study has 
clearly shown the need for a well-planned and effective 
maxillofacial prosthodontic service to be developed in the 
Witwatersrand-Vaal area.
OPSOMMING
Hierdie studie is onderneem om die behoeftes van hierdie 
pasiente te bepaal en om toekomsbeplanning van die 
dienste moontlik te maak. ’n Vraelys is aan 100 pasiente 
wat vorige behandeling van die aard by die Departement 
van Tandheelkundige Prostetiek aan die Universiteit van 
die Witwatersrand, Johannesburg, ontvang het uitge- 
stuur. Die hoofklagte van die pasiente was die lang 
tydsverloop voordat behandeling ’n aanvang kon neem. 
Hierdie studie toon dat daar ’n behoefte bestaan vir yn 
goedbeplande en effektiewe kaak- en gesigsprostodon- 
tiese diens vir die Witwatersrand-Vaalgebied.
INTRODUCTION
Deformities or mutilations of the head and neck region 
may be the result of congenital defects, trauma, disease, 
or surgery. Multilation of a body part, particularly in the 
head and neck region, can be a traumatic factor affecting 
the psyche (Jebreil, 1980). The psychological inability to 
compensate for the physical loss may have a devastating 
effect on an individual.
The surgical removal of a facial structure and the resul­
tant defect lowers a person’s image of his social accepta­
bility (Hutcheson and Udagama, 1980). Worse still, the 
changes caused by radical surgery are often viewed by 
patients as the termination of their former life, and they 
view any facial deformity as setting them apart from 
other members of society. (Shipman and Bader, 1979). 
The relationship between the actual severity of disfig­
urement and the degree of psychological stress experi­
enced is not a simple one (Bailey and Edwards, 1979). 
Often patients whose disabilities are relatively slight 
may have greater expectations for the restoration of 
their appearance, and therefore may be the more disap­
pointed since their hopes are unrealistically high (Beder 
and Weinstein, 1980).
The need to minimise negative responses to facial disfig­
urement in the most sensitive immediate post-surgical
phase is essential for the positive self-esteem and effec­
tive rehabilitation of the patient (Shipman and Bader, 
1979). An immediate replacement prosthesis helps the 
patient through this emotionally taxing phase and allows 
him to maintain his concept of self-dignity (Hutcheson 
and Udagama 1980).
The artificial replacement of missing body parts has 
existed as long as man himself, and has increased in the 
last four decades. The ability of medical and dental 
specialists to rehabilitate patients with defects of the 
head and neck has also become greater with the devel­
opment of materials and techniques but this has been 
countered by population growth with an accompanying 
increased demand for treatment. It would appear that 
today, the only acceptable and effective method of 
management of the head and neck patient is by a multi­
disciplinary team approach (Rahn and Boucher, 1970; 
Desjardins, 1979; Gillis, 1979; Sela and Lowenthal, 
1980; Parr, Goldman and Rahn, 1981). This necessitates 
that maxillofacial prosthodontic centres be designed as 
integral parts of the medical centres which they are 
designed to serve (Chalian, 1978).
An attempt has been made over the past 5 years to 
integrate, in an informal way, the activities of the Maxil­
lofacial Prosthodontic Service of the Department of
Journal of the D. A.S. A. — April 1986
181
E.M. Bonner, J.F. Wolfaardt and P. Cleaton-Jones
Prosthetic Dentistry of the Oral and Dental Teaching 
Hospital of the Witwatersrand, Johannesburg, with the 
other services providing treatment for patients with de­
formities of the head and neck. This has led to rapid 
increase in demand for access to the maxillofacial pros- 
thodontic service by patients. The result of this has been 
that there is inadequate staff to attend to cases requiring 
surgical prostheses, and waiting lists exist for surgical, 
interim and definitive prostheses. The objective of this 
part of the present study was to determine the value of 
the existing maxillofacial prosthodontic service to those 
patients who had been treated at the Oral and Dental 
Teaching Hospital of the Witwatersrand. From this in­
formation it was hoped that knowledge could be gained 
as to how the needs of patients in the future can be met in 
planning for an adequate maxillofacial prosthodontic 
service.
MATERIALS AND METHODS 
Methods of survey of patients
A total of 100 questionnaires (copy available from auth­
ors) was sent to patients randomly selected from those 
who had been treated for maxillofacial defects at the 
Department of Prosthetic Dentistry, Oral and Dental 
Teaching Hospital of the Witwatersrand, Johannesburg. 
These were accompanied by a covering letter explaining 
the nature of the investigation, and a self-addressed 
envelope. All replies were anonymous.
Statistical analysis
The replies received were transferred to computer 
punch cards and the statistical analysis which was re­
stricted to descriptive statistics was carried out using the 
SAS* (Statistical Analysis System) Version 79,5 on an 
IBM 370/158 Computer.
RESULTS
Of the 100 questionnaires sent out, 52 questionnaires (52 
percent) were returned. This was considered to be a 
good response, considering that at least some of those 
who had been treated had probably either moved or 
died. The inferences drawn are representative only of 
those who had replied and not of the whole group of 
patients surveyed.
Certain questions were not answered by all the patients 
who replied. Therefore the cumulative frequency in the 
tables which follow will not always total 52.
Age of patients
The age distribution of the patients who returned the 
questionnaire has been detailed in Table 1.
It can be seen from Table 1 that 63,5 per cent of the 
patients who replied to the questionnaire were between 
51-80 years of age. Of these 57,7 per cent were female.
Ethnicity of patients
The ethnic groups of the respondents are shown in 
Table 2.
* SAS (Institute Inc.), University of North Carolina, U.S. A.
Table 1 — Age distribution of patients
Frequency Percentage
1-10 2 3,8
11-20 6 11,5
21-30 5 9,6
31-40 1 1,9
41-50 4 7,7
51-60 10 19,2
61-70 12 23,1
71-80 11 21,2
81 + 1 1,9
Total 52 100,00
Table 2 — Ethnicity of patients
Frequency Percentage
Black 9 17,3
Indian 1 1,9
Coloured 3 5,8
White 39 75,0
Total 52 100,00
Cause of the problem
Patients were asked to indicate the broad cause of their 
problem (Table 3).
The commonest cause was disease.
Table 3 — Cause of problem
Frequency Percentage
Born with problem 7 13,5
Caused by an accident 7 13,5
Caused by disease 36 69,2
Not stated 2 3,8
Total 52 100,0
Prior treatment
Patients were asked to indicate what form(s) of treat 
ment they had received prior to coming to the Oral and 
Dental Hospital. The frequency of these treatments is 
shown in Table 4, and because several patients had more 
than one type the cumulative frequency is greater than 
52.
Table 4 — Prior treatment
Frequency
X-Ray (cobalt) 16
Surgery 34
Chemotherapy 4
Not sure 13
Total 67
The mode of treatment carried out at the Oral and Dental 
Hospital
Patients were asked to indicate what treatment they had 
required. Table 5 shows that the majority (73,1 per cent) 
required intra-oral appliances.
Tydskrif van die T.V.S.A. — April 1986
182
Maxillofacial Prosthodontic Service
Table 5 — Treatment required
Frequency Percentage
For use inside the mouth 38 73,1
For use outside the mouth 10 19,2
Both 4 7,7
Total 52 100,00
Length of wait for an appointment
Patients were asked to specify how long they had had to 
wait for an appointment at the Oral and Dental Hospi­
tal. The frequency of the length of wait is tabulated in 
Table 6. It will be seen that 60 per cent had had to wait a 
month or longer; 25 per cent had had to wait for three 
months or longer.
Table 6 — Length of wait for an appointment
Frequency Percentage
1 week 21 40,4
1 month 17 32,7
3 months 8 15,4
6 months 4 7,7
1 year or longer 2 3,8
Total 52 100,0
Progress of Treatment
78,8 per cent indicated that the course of treatment had 
progressed smoothly and 86 per cent felt their treatment 
had been succesful. 74,5 per cent of those who replied 
were still wearing the appliances which had been sup­
plied. However, 64,7 per cent of those who replied felt 
they needed more treatment, and 66,7 per cent wanted 
further treatment.
Information provided prior to treatment
88,5 per cent stated that they had been given adequate 
information about their treatment before commence­
ment, and 28,8 per cent felt that more information 
would have been helpful. This is in direct contrast to the 
literature reviewed.
DISCUSSION
No reference to a previous similar study could be found 
in the literature and thus no direct comparison to other 
workers was possible.
When the study questionnaire was sent out, patients on 
the waiting list for maxillo-facial prosthetics (at present 
greater than one year) were not included. The results of 
this study, therefore, only reflect the attitudes and de­
sires of patients who had had maxillo-facial prosthetic 
treatment. It is possible that the replies of these patients 
were biased in favour of what they perceived the investi­
gators might want to hear.
Most patients treated were older than 50 years, but 
almost a quarter were below 30 years. In the design of a 
suitable treatment centre allowance should be made for 
the needs of both young and old. The age distribution 
also supports the importance of psychological counsel­
ling as an integral activity within the maxillo-facial pros­
thetic service.
The limited staffing of the service and historical ties to 
the Johannesburg Hospital was responsible for the im­
balance of ethnic distribution of patients. In the future 
planning of a service it is essential that this imbalance be 
eliminated. Since the service must be centralized, suffi­
cient clinical staff must be made available to allow pres­
ence at head and neck, cleft palate, radiotherapy, oph­
thalmic and other clinics of the Johannesburg, Hillbrow, 
Baragwanath, Coronation and other hospitals. Once 
patients have been seen and discussed with the medical 
personnel of these hospitals, transport arrangements 
will have to be made to move patients to the centralized 
maxillo-facial prosthetic service.
The patient survey emphasized the importance of dis­
ease as the main cause of head and neck defects, espe­
cially in those above 50 years of age. Of the patients who 
responded a significant number had had radiotherapy 
and chemotherapy which frequently have sequelae 
which may result in changes in the oral environment. 
Careful control of the patient’s oral health prior to and 
after such treatment can greatly enhance the outcome 
of dental treatment. It is essential therefore that ade­
quate facilities and personnel be provided for the main­
tenance of oral hygiene. It is also for this reason that 
many centres will include a clinician familiar with oral 
medicine.
It was found that 73,1 per cent of respondents had had 
intraoral treatment and 19,2 per cent received paraoral 
treatment. Only 7,7 per cent of patients required combi­
nation prostheses and this would seem to indicate that 
for the sake of efficiency of the service in a major centre 
it would be worthwhile to have staff dedicated to facial 
prosthetic work while others would be dedicated to 
intraoral work since the two areas require highly devel­
oped and specialized but differing skills. This has in fact 
been the trend in most major maxillo-facial prosthetic 
centres throughout the world.
A large number of patients indicated that they both 
needed and wanted further treatment, but these were 
those who had been successful in obtaining maxillo­
facial prosthetic treatment, not those on the waiting list 
(approximately one year). Even of those treated, ap­
proximately 60 per cent were required to wait a month or 
longer and 25 per cent had to wait for 3 months or longer 
before any treatment could be initiated. The success rate 
of treatment has been shown to increase as waiting time 
decreases (Sela and Lowenthal, 1980) due to psychologi­
cal reasons.
The major problem appears to be that demand for treat­
ment overloaded the resources available to provide that 
treatment. This resulted in long waiting lists onto which 
patients were placed before they could be seen. Compli­
cations arise from this as patients cannot be provided 
with adequate surgical and interim prostheses. Control 
of treatment is therefore lost early on and the entire 
treatment period is greatly extended with considerable 
increases in cost and loss of efficiency. Maxillofacial 
prostheses, particularly facial prostheses, require regu­
lar remaking. The average lifespan of a prosthesis is 
10 months (Jebreil, 1980). The waiting list results in 
patients, once having had a prosthesis made, not being 
able to obtain replacement prostheses as preference has 
to be given to new, as yet untreated patients. The prob­
Journal of the D. A.S. A. — April 1986
183
E.M. Bonner, J.F. Wolfaardt and P. Cleaton-Jones
lem remains that due to the multidisciplinary nature of 
head and neck rehabilitation it is difficult for maxillo­
facial prosthodontic treatment to be undertaken in the 
private sector. This means that the patient with a head 
and neck defect is often obliged to make use of the 
institutionalized maxillofacial prosthodontic service 
where there is little or no hope of immediate attention. 
The consequences of this, to many of these patients, are 
extremely serious as without the necessary treatment 
they are unable to eat, speak or face their families due to 
the mutilations with which they have been left.
CONCLUSIONS
The results of the present study clearly show the need for 
a well-planned and effective maxillofacial prosthodontic 
service to be developed in the Witwatersrand-Vaal area. 
In its present form, limited by lack of trained manpower 
and inadequate facilities, the existing service at the Oral 
and Dental Teaching Hospital of the Witwatersrand, 
Johannesburg does not meet the demands of either the 
referring practitioners or of the patients. With this deter­
mined anticipated escalation in demand it would appear 
that the development of the service should be seen as a 
matter of urgency.
REFERENCES
Bailey, L.W. & Edwards, D. (1979) Psychological considerations in maxillofa­
cial prosthetics. Journal of Prosthetic Dentistry, 34, 533-538.
Beder, O.E. & Weinstein, P. (1980) Explorations of the copings of adolescents 
with orofacial anomalies using the Cornell Medical Index. Journal of Pros­
thetic Dentistry, 43, 565-567.
Chalian, J.A. (1978) Education in maxillofacial prosthetics. Journal of Pros­
thetic Dentistry, 40, 579-582.
Desjardins, R.P. (1979) Ch. 3 : Examination and diagnosis & Ch. 4 : Relating 
examination findings to treatment procedures. In: Maxillofacial Prosthetics 
Editor: Laney, W.R., p.42 & p.70 Littleton: P.S.G. Publishing Co.
Gillis, Jnr. R.E. (1979) Psychologic implications of patient care. In: Maxillofa­
cial Prosthetics. Editor: Laney, W.R. Ch. 2, pp.21-40. Littleton: P.S.G. 
Publishing Co.
Hutcheson, P.E. & Udagama, A. (1980) Surgical nasal prosthesis. Journal of 
Prosthetic Dentistry, 43, 78-81.
Jebreil, K. (1980) Acceptability of orbital prostheses. Journal of Prosthetic 
Dentistry, 43, 82-85.
Parr, G.R., Goldman, B.M. & Rahn, A.O. (1981) Maxillofacial prosthetic 
principles in surgical planning for facial defects. Journal of Prosthetic Den­
tistry, 46, 323-329.
Rahn, A.O. & Boucher, L.J. (1970) General considerations. In: Maxillofacial 
Prosthetics — Principles and Concepts, 1st Ed., Ch. 1, pp. 1-5. Philadelphia: 
W.B. Saunders.
Sela, M. & Lowenthal, U. (1980) Therapeutic effects of maxillofacial pros­
theses. Journal of Oral Surgery, 50, 13-16.
Shipman, B. & Bader, J. (1979) Immediate autopolymerizing acrylic resin facial 
prosthesis. Journal of Prosthetic Dentistry, 42, 320-326.
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Tydskrif van die T.V.S.A. — April 1986
184


The need for and value of a maxillofacial prosthodontic service in the Witwatersrand-Vaal area: part II: A survey of patients who required maxillofacial prosthodontic treatment

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The need for and value of a maxillofacial prosthodontic service in the Witwatersrand-Vaal area: part II: A survey of patients who required maxillofacial prosthodontic treatment

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