My Greatest Reward

July 7th  began like any other day for me. I remember that there was a beautiful sunrise that morning. I had a compressed, busy schedule in my oral and maxillofacial surgery practice in Lake Oswego. “We have a trauma patient coming in, Doctor” my front staff informed me when I arrived at my office. We already had fifteen patients scheduled that morning for me to see, three of whom were surgery patients. How would I find the time to see this other patient?

My add on trauma patient turned out to be a wonderful woman named Sunny. From my first meeting with her, I could see why her friends had given her this affectionate nickname. Sunny has a type of effervescence that surrounds her. Joy bubbles out of her. You canʼt help feeling good just by being in her presence. At this first meeting, I was struck by her amazingly positive attitude. It was hard for her to speak clearly because part of her upper right jaw was missing. She kept holding up her hand to hide the right side of her face. Slowly she was able to tell me her story.

Sunny had been at an outdoor function with her soon-to-be husband on a Saturday afternoon. As she was walking along an unfamiliar path, her foot slipped and she went down. This happened so quickly that she was not able to break her fall, but landed on her right face against a curb. Stunned and bleeding profusely, she sat up. Part of her upper jaw was missing. Looking down, she saw what she thought were bits of bone and tooth on the ground.

Sunnyʼs partner took her immediately to the closest emergency room for care. They were hoping to have a diagnosis made and treatment. An exam was performed as well as imaging studies. Since this hospital was not part of Sunnyʼs health maintenance organization (HMO), she was told by the emergency room to contact the HMO for definitive care. When she called the HMO that evening, she was told that she would have to wait a week for an exam and treatment (she was told this is their policy to allow for swelling to resolve). When Sunny was finally able to see a surgeon at her HMO hospital, it was six days later. The surgeon told her that she had a dental injury and would need to follow up with her dentist. There wasnʼt anything he could do for her. She was sent home with a prescription for Amoxicillin.

Sunny called her dentist from the parking lot of the HMO in tears. She knew that something was seriously wrong with her and she was struggling to understand why she couldnʼt get the care she needed. Her dentistʼs receptionist asked her to come in to his office immediately. When the dentist saw Sunny, he knew that this was more than a dental injury. He could see that part of her upper jaw appeared to be missing, as well as teeth in the anterior maxilla. His office called my office, thus the “add-on” patient for an already busy morning.

Examination of Sunny demonstrated a severe, avulsive injury involving the right anterior maxilla. Computed tomography scanning performed at the emergency room six days previously demonstrated fractures extending through the frontal process of the right maxilla, including the anterior nasal spine and vomer. She had fractured teeth #7 and #8 which were displaced into the right maxillary hard palate and not visible in the oral cavity. Tooth #9 also was extruded and was in hyperocclusion with her mandibular dentition.

Sunnyʼs dentist had sent electronic records for me to review and I was able to review her CT scan. I was stunned by the severity of her injury. At this point in my career, I have seen many, many things. Not much surprises me anymore when it comes to the maxillofacial skeleton. But I was not prepared for how bad this injury was given the mechanism of injury. What Sunny had was more similar to a gunshot wound without the accompanying soft tissue devastation seen with a high velocity injury.

I knew that Sunny needed surgery and that she needed it soon. I also knew that she needed to be asleep for what I was planning for her. Since she had eaten that morning, we scheduled her for surgery the next day. I explained to her the nature of her injuries, that the wound needed to be cleaned, the broken bones stabilized and the damaged teeth removed. I explained that she might need root canals on some of her other teeth, and that she might require more extensive reconstructive surgery to rebuild the missing part of her jaw. I told her that she would also probably require dental implants since her teeth were damaged beyond repair. I prescribed antibiotics and pain medication for her to begin immediately. Sunny agreed to everything that I suggested. One concern was her upcoming wedding. Could I have all the reconstruction done in time for her wedding which was scheduled for next December? I told Sunny that I would try my best.

Over the next year Sunny underwent several surgeries to rebuild her maxilla. We began with debridement and fixation of broken bones. As I suspected, the right anterior maxilla had been pulverized by her fall and her wound was quite dirty. I found pebbles and asphalt at that first surgery. I confirmed that Sunny would require a large bone graft to reconstruct her upper jaw if she ever had any hope of having a normal facial appearance. Hip grafting to the right maxilla was completed in February and three dental implants were placed in June.

Sunny handled all aspects of her year-long reconstruction with grace and humor. She is a third grade teacher and saw an opportunity to use her injury to teach her class of eight year olds about anatomy and jaw reconstruction. She told me on one follow up visit, “I took out my prosthesis and showed my students how I was missing teeth, just like them. The kids loved it and had all kinds of questions about how my teeth would be put back. They couldnʼt believe that part of my hip would become my new jaw!”

It was an amazing privilege to provide surgical care for Sunny following her facial injury. I feel so grateful that things went well: healing progressed as expected and we achieved the outcomes we were hoping for. I canʼt claim sole responsibility for her healing. Sunnyʼs reconstruction was brought about by a dedicated group of professionals whose sole goal was to restore her to health.

Sunnyʼs health maintenance organization initially denied medical benefits for her reconstruction. Several letters were written from those involved in Sunnyʼs care and eventually she received the benefits needed to cover the cost of her reconstruction. Martha, my front office insurance expert, was instrumental in making this happen. I am grateful to Sunnyʼs dentist who recognized that she needed specialty care. I also feel lucky to have such a positive working relationship with Dr. Scott Dyer, who handled Sunnyʼs prosthodontic reconstruction.

Sunny recently stood before her friends and family as a bride and made a commitment to her partner just a few weeks ago. She told me via email “The wedding was spectacular and everything that we had both hoped for.” For a surgeon, there just isnʼt any higher reward than that.