May 31, 2017

Written by Terry McGovern (class of 2016-2017)

I hate running late and this morning I was. After concluding my last ICU preceptorship shift the night before, I had a hard time getting out of the house early enough. Compounded by especially poor parking near Highland, I was late.

Got to the rounding room 10 minutes past 7. Snuck in the side door, and sat away from the table full of residents, and was surprised to see Dr. Harken was not there. Dr. Palmer was doing a review of carcinoid syndrome. Gastric carcinoids, duodenal endocrine tumors, mid gut tumors, and the treatment of such diseases.

Oral boards are coming up soon and I imagine the senior residents are in full preparation mode.

Iheaded over to OR and looked at the board.It seems that Wednesdays are a day for oral surgery/ oral maxillofacial. Since I hadn’t seen any of those (and a couple of more interesting surgeries were postponed ) I headed to OR 4 to observe. I heard some OR joking about the fact that Oral/maxillary never use all their allotted surgery time.

First patient was a 20 yr. old male who had some severe dental issues. Impacted wisdom teeth being the least of it. The surgery was a Bilateral mandibular maxillary incisional biopsy of multiple maxillary and mandibular OKC’s

“An odontogenic keratocyst (OKC) (also referred to occasionally as keratocystic odontogenic tumor, KCOT)[1] is a rare and benign but locally aggressive developmental cyst. It most often affects the posterior mandible. It most commonly presents in the third decade of life.[2]

According to Wikipedia “In 2017, the new WHO classification of Head and Neck pathology re-classified OKC back into the cystic category. It is no longer considered a neoplasm as the evidence supporting that hypothesis (e.g. clonality) is considered insufficient. However, this is an area of hot debate within the head and neck pathology community, and some pathologists still regard OKC as a neoplasm despite the re-classification.”  This is a typical view at what it looks like in an x-ray.Screen Shot 2017-10-15 at 6.19.57 PM.png

Attending was Dr. Limchayseng, aka “Dr. Louie”. When I introduced myself and told him about OREX, he humorously said “Fine with me, I don’t own the place”.

Senior residents doing the surgery were Austin Eckard DMD and Sonia Bennett DDS, and Bruce Sterling, DDS who was doing the Anesthesiology under the supervision of the amazing Dr. Jain (SP?) with the ever welcoming Glenda RN and Chelsea OR Tech.

They started at 8:50am. It wasn’t the greatest surgery to watch as you can’t see much in a patients mouth unless you are the surgeon. But it was a fascinating surgery to watch and to be able to look at the posted x-rays and imagery. I had never heard of this before so I wasn’t surprised when I found out this is a rather rare condition. Looking at the X-ray/imagery I wondered how painful this condition was pre-surgery for this young man.

Here is an image from the internet that is somewhat akin to what the patient presented with though our patient had lateralized teeth in the front in contrast to this one.
Screen Shot 2017-10-15 at 6.24.08 PM.png

They removed a total of 6 teeth and a lot of keratinized tissue, which was sent to pathology. As I understand it, keratinized tissue displaces normal bone tissue.

Dr. Louie said that this patient definitely had a “syndrome”, which I assumed meant this was a genetic disease that was rather rare to see. One quote from Dr. Louie after noticing some less than perfect suturing, “Mediocrity is not acceptable”.

We finished up at 11:50am. A break was in order.

Since I was on their schedule, and the residents had a second surgery scheduled, I decided to watch their next oral/mandibular surgery instead of jumping into another surgery already in progress.

The 2nd surgery was a fractured mandibular repair of an ICU patient who had been hit while riding his bike. He had a closed head injury and was intubated, and due to the type of surgery they had to intubate him thru his nose for the surgery. There was some concern that due to the patient’s closed head wound/trauma that they would want to do this surgery as quickly as possible to avoid any complications or Inter-cranial pressure increase.

Attending was Dr. V. Farhood, who was a very welcoming and lighthearted surgeon, who was also supervising a surgery in another OR simultaneously’ .

Officially called an ORIF of Mandible Fracture post car accident, and start time was around 12:30pm.

The most interesting part of this surgery was that the surgeons did the repair from the inside of the mouth. They cut back the tissue below the teeth and gums revealing the bone and the fracture. They spent a lot of time and energy getting the alignment just right before they placed the plate, with six 2mm wide and 15 mm long screws, to join the front of his mandible together.
Screen Shot 2017-10-15 at 6.29.51 PM.pngThis image from the internet gives a sense of what it looks like, but in the surgery I saw the fracture was midline and almost perfectly vertical with only 1 longer plate used.

They finished up at 2:40pm concluding the approximately 2-hour long surgery.

There was one more surgery on the board but after a long week of, finishing school, and graduation, I opted to go home at 3. Another varied and interesting day in the OR.

  1. Madras J, Lapointe H (March 2008). “Keratocystic odontogenic tumour: reclassification of the odontogenic keratocyst from cyst to tumour”. J Can Dent Assoc. 74 (2): 165–165h. PMID 18353202.
  2.  MacDonald-Jankowski, D S (2011). “Keratocystic odontogenic tumour: systematic review”. Dentomaxillofacial Radiology. 40 (1): 1–23. ISSN 0250-832X. doi:10.1259/dmfr/29949053.



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