A Clinical Challenge… Delayed Treatment: ORIF Vs IMF

A 42 year old male,waiter by profession walked into Denty’s Andheri with history of trauma which had happened 5 weeks back. On enquiry, the old man had got into a common brawl with the owner of the restaurant who punched him on the right side of the face. After the incident, the man consulted a local physician who prescribed him medication (painkillers and antibiotics). He did not undergo any other investigations or treatment. Two weeks ago, the patient reported to our clinic with the complaint of difficulty in chewing food and inability to occlude.

1
As a dentist working in a private setup, one often comes across trauma patient, weeks or months after the actual incident took place. Furthermore decision making regarding treatment plan depends on a multitude of factors (e.g. Type of fracture; current symptoms; patients expectations; socio-economic status of patient; functional and esthetic restoration etc) which poses a challenge to the clinician.

2
On extra oral examination there was a step deformity and swelling was observed. Mouth opening, however was not restricted. Upon Intraoral examination the occlusion was deranged –shifted to left side but there wasno mobility between the fractured segments in the mandible. There was mobility w.r.t 43 and 44 (grade 2).

OPG revealed fracture line extending from the right lower border of the mandible upto the region between 43 and 44. An undisplaced left condylar fracture was suspected however the man was unwilling to undergo any further investigations. The man was given an option to undergo further investigations (for suspected condylar fracture) and ORIF under GA (re-fracturing of the fracture fragments followed by reduction and placement of miniplates). However, due to financial and other constraints he was unwilling to understand or undergo any complicated procedures. He firmly requested for his function to be restored as all he desired was, to be able to bite and eat. These factors including the delayed representation of case along with absence of any substantial clinical signs and symptoms; were the basis for us to modify our treatment.

3
After complete Investigation and evaluation, the treatment option given was closed reduction with IMF. Upper and lower Erich arch bars were placed and IMF achieved using heavy elastics. Man was placed on complete liquid diet and elastics were changed for every 10 days. The arch bars were removed after achieving acceptable occlusionand symptom free which took place within 7 weeks of time.

Delayed representation of case poses a challenge in treatment planning. In this case the patient’s socio economic status along with his expectations regarding treatment outcome were the other major limiting factors. The treatment outcome for this patient was satisfactory and the patient walked out of our clinic with a big smile on his face and words filled with gratitude.

Treatment plan needs to be modified considering a variety of factors. The clinician thus must be innovative and constantly updating his knowledge base and clinical acumen. However, we must make constant efforts to spread awareness amongst our society which will result in early diagnosis & treatment. This will help us in achieving ideal treatment outcomes and excellent patient satisfaction.

Information of the Doctor:
Dr. Vividha Singhania MDS [Oral & Maxillofacial Surgeon]

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Hyderabad – 500 034

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