Thursday, August 20, 2009

A place to find help.

After receiving positive feedback from other health care professionals its seems appropriate and uplifting to share Simon's story of healing (Simon was welcoming of photographs).  The best stories are that of our patients and their experiences at Kijabe.

Simon came to Kijabe dental six weeks ago from a place just 20 km up the road.    He is 29 years old, Kikuyu, and in good health.  

The painless swelling in his right cheek had grown steadily for 8 years to its present size.   Beyond the obvious disfigurement it does not prevent Simon from eating or holding a normal job.  It is firm to the touch.  Intra-orally the mass had malpositioned, or avulsed or mobilized teeth #19-32.  This intrabony swelling extended from the alveolar crest to the inferior border of the mandible.  The swelling has pushed into the floor of the mouth pushing the tongue upwards. 

A natural question for myself and most any observer is, "How did Simon let this get this big?"  Simon has been proactive about receiving treatment for the past two years.   The process of receiving surgical care in Kenya can be long and convoluted starting at a small dispensary where you might see a nurse, referred to a sub-district hospital where you might see a clinical officer, to a district hospital where if you come the right day you might see a dentist, to a national hospital where you would find and oral maxillofacial surgeon.  
Eventually Simon was able to attain an OPG (x-ray) of his mandible and maxilla at a National Hospital.  At this time he was given a prescription for a titanium mandibular replacement (much as you or I would be given a prescription for medicine).  In Kenya it is common to receive a prescription and buy your artificial hip, or knee, or in this case mandible before surgery is allowed.  
Simon saved and raised nearly 80,000 (1,000 USD) to purchase the titanium replacement. His surgery was finally scheduled at a National Hospital. It was cancelled.  It was rescheduled, and cancelled again.  He was not rescheduled.  At that time Simon came to Kijabe.
The incisional biopsy was  completed at Kijabe and as we expected it came back positive for Ameloblastoma.  Ameloblastoma is a benign slow growing neoplasm that typically presents in the mandible in the third to fifth decade of life more commonly in men.  Fortunately Ameloblastomas are treatable, but require aggressive surgical approach of partial mandibulectomy establishing clean margin of 1.0 cm past the radiographic extent of the lesion.

This treatment is beyond the scope of my training and profession, but one of the benefits of missionary medicine is the chance to work alongside dedicated and talented Christian surgeons.   

The 6 hour surgery involved a split lip incision extending below the chin and to the angle of the mandible.  After this the tumor was disected away from the viable soft tissue.  Finally the mandible was sectioned in the ramus on the right side and medial to the 3rd molar on the left side. 
Then a 10 inch segment of the fibula from the patient's left leg was harvest as a graft to replace the missing segment of the mandible.  The fibular bone was sectioned 3 times to approximate the form of the mandibular ridge.  Mini plates and bicortical screws were used to attach the fibular bone segments together and to the vital mandible.  The periosteum, facial layers, and skin was closed and a drain was sutured into place.

Simon was in the ICU several days after surgery mostly for access to urgent care if any airway issues arose.  Unfortunately, since the surgery the wound in his mouth has dehisced twice exposing the graft.  It has since been resutured.  He is just recently discharged. 

We are happy Simon found Kijabe, and that Kijabe was able to help him.  We pray he continues to heal and the mandibular graft takes.  



Ana said...

That's an amazing story, Malin. Thanks for sharing! With all the health care reform debate going on state-side, regardless of my position, it makes me thankful for the doctors and medicine we have available here. Great job!

Anonymous said...

Fascinating work, Malin. It must have been great to be there and help this young man. He was certainly committed to getting the care he needed. I would imagine, in that environment, it would be so discouraging and so easy to just give up. Do you know where he is spiritually? Was he praying for help? Were others praying for him? Praises for whatever or whomever kept him going until he found your team.

I will be praying for his recovery.

Hope your day is blessed,

hankwillisdds said...

There was a good case study/pathology article in this month's JADA about ameloblastomas. Good case report here.

hankwillisdds said...

Malin, email me if you want the JADA PDF article.

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