The following information is designed to provide the patient and family with more detailed information regarding planning and recovery for orthognathic surgery. This has been divided into two basic areas entitled "Preoperative Instructions" and "Postoperative Instructions." Much of this information will be reviewed by our office staff and we encourage you to use this as a reference. Please do not hesitate to contact our office at any time if there are further questions.
As you recall from our previous pamphlet, there will be a preparation phase prior to you surgery during which time your orthodontist will be completing the necessary changes to ideally prepare you for your surgical correction. This period is variable and lasts approximately 12-16 months. Your orthodontist will typically inform you when he or she feels you are adequately prepared for your surgery. You will then need to make an appointment with your surgeon's office for a presurgical consultation. During this consultation your surgeon will complete a brief examination and confirm your preparation for surgery. Once the surgeon has determined that you are ready to proceed with your surgical correction, several areas of coordination need to be addressed. The patient-care coordinator at your surgeon's office will then arrange a surgical date which is convenient for you. Once this date for surgery has been chosen, several appointments will be necessary prior to this date.
The following checklist will summarize these appointments:
Check that your insurance company has provided preauthorization 3 months prior to surgery. (Predetermination will be initiated at your first surgical consultation.)
Obtain a lateral cephalometric x-ray within 6 weeks of the surgical date.
Make an appointment with your orthodontist to have surgical arch wires placed approximately 3-4 weeks before surgicaldate.
Make an appointment with our office for final records 10-14 days before your surgical date. Postoperative instructions are reviewed at this appointment.
Make an appointment for a history and physical examination at our office within 1 week of your surgical date. Further pre- and postoperative information will be reviewed by Dr. Trimble.
Make an appointment to view our educational videotape on orthognathic surgery if you have not already done so.
Make an appointment with the hospital to register and have any laboratory work done within 2-3 days of your surgical date.
Our office staff and nurses will make every effort to assist you in arranging these appointments so that your preoperative preparation goes smoothly.
The following information is provided to ensure that many of the details of postoperative care are covered prior to your surgical procedure. This ensures a smooth and uneventful recovery. It has been our experience that the more information and preparation patients have prior to their surgery, the more easily they are able to manage their postoperative care.
There are several aspects of your postoperative care which will require special attention. These areas of concern are listed below in the sequence with which you will have to manage them after your surgery. The following topics will be covered: Swelling · Splint use and jaw opening · Fluids/drinking · Medication · Diet · Hygiene · Activity · Work/School · Bleeding/swelling.
It is difficult to predict what you will remember immediately following surgery. You may remember waking up in the recovery room or you may not recall this event and only remember waking up in your room. Regardless, be assured that there will be experienced and caring nurses and staff to attend to your needs. When you awake, you may have some concerns. You will likely have a small oxygen mask lightly over your face; this is routine. If you have some fluids in your mouth or stuffiness in your nose, this will be removed with a small suction tube. Remember - your jaws will be held together with some elastics-not wires. Many of these things can cause you to feel uncomfortable or even panicky. Remember to relax and listen to the staff -you are in no danger. Your jaws are not wired together and usually you will be able to open the jaws against the force of the elastics. We would prefer that you don't. This resting of the jaw will help minimize swelling.
You will be positioned with your head up. This will help minimize swelling. This "head up" position should be used for the first 7-10 days to help reduce swelling. Expect the peak of your swelling to occur 48 hours after surgery and most should be gone by 7-10 days. In the hospital, the bed will be flexed in the middle to prevent you from sliding to the foot of the bed. At home, propping up your mattress at the head of the bed and under the foot of the bed will help also. Spending a lot of time in a "Lazy Boy" type chair is an excellent alternative. Remember, keeping your head above the level of your heart is what helps reduce and minimize swelling. How much swelling you will actually have varies significantly from patient to patient.
In the hospital, several additional aids will be used to help minimize your swelling. Medications will be administered to help decrease swelling. Ice packs will also be used. Constant use for the first 12 -24 hours is most effective. The nurses will assist you with ice packs which should be applied for 20 minutes and removed for 10 minutes.
Nasal swelling and stuffiness can also be a problem after upper jaw surgery. This will tend to be worse 48 hours after surgery and will then begin to decrease.
The use of nasal spray and special cleaning of the nose with Qtips and hydrogen peroxide will be reviewed with you prior to surgery. Warm packs to the face after the first 48 hours will help increase blood supply and reduce swelling, speeding the resolution of discoloration associated with bruising. If bruising occurs it will be evident 4-5 days after surgery.
Just a final word regarding your jaw surgery and safety. First, the elastics can be easily removed by you. In the unlikely even vomiting occurs, it is most important to position yourself properly rather than to try to take the elastics off. If you are sick, position yourself over a basin or toilet bowl and let the fluids pass between the spaces in your teeth and out your nose. You will not choke. There is no need for you to take wire cutters home with you.
Following jaw surgery there is frequently some numbness in the upper or lower lip, or both. When this is combined with facial swelling and soreness due to incisions inside the mouth, a task as basic as drinking may present difficulties. There are several tips which may help you:
You should be drinking a fair amount of fluid after jaw surgery. Daily amounts should be between 2 -3 liters. Fruit juices are an excellent source of fluid, especially apple juice. This is a major goal after surgery. The most frequent cause for a delay in discharge from the hospital is a lack of adequate fluid intake. Always have some fluids in front of you and drink frequently to consume 2-3 liters in 24 hours. The nurses will be encouraging you to drink early.
Attempt to drink from a cup if possible. While some fluids may be spilled when drinking in this manner, this is still the most effective way of taking fluids.
Place a small towel under your chin if necessary and place a small amount of fluid in your cup. Tip your head back slightly while pouring in the fluid slowly, a little at a time. Close the lips together and swallow. If you have difficulty with this, then try doing it in front of the bathroom mirror over the sink. You will find this gets easier the more times you drink.
REMEMBER: TAKING ADEQUATE AMOUNTS OF FLUIDS IS ESSENTIAL FOLLOWING SURGERY
Several medications will be used around the time of your surgery. Antibiotics will be given during your hospital stay through the intravenous. Upon your discharge from the hospital, these antibiotics will be given in pill form.
Pain medication will also be given after your surgery. In the first 24 hours following your surgery, the pain medication will be administered through intravenous. You will regulate the amount of pain medication you are given. It must be emphasized that this route of administration is only used while you have the intravenous, which is approximately 24 hours. We always encourage you to use oral pain medication as soon as possible as this will expedite your discharge from the hospital and allow for a smoother transition. Upon your discharge from the hospital, your pain medication will be in pill form. In general, there is less pain than most would anticipate with this surgery. This is due to the disfunction of the sensory nerve in the areas of surgery which minimizes your ability to feel discomfort.
Both the oral pain medication and antibiotics will be taken orally. This is best accomplished by removing the elastics and your surgical splint. A vast majority of patients find liquid medications of little advantage and certainly messier.
This is an important part of your surgery. This will help balance your bite and train your muscles to function in the new jaw position. It should be worn full-time except when you are eating or cleaning your mouth. You will be shown how to remove and replace it before and after you leave the hospital. It has indentations on it that fit the teeth on the top and bottom and thus will only fit one way.
Generally, the splint will be worn continuously for the first 6-8 weeks following surgery. Dr. Trimble may elect to discontinue the splint use early, especially in upper jaw surgery alone. However, the splint should be expected to be worn for at least 8 weeks. Your orthodontist may continue to use the splint for a short period of time to assist treatment. Failure to wear the splint may cause pain or may result in significant change of the bite! The splint will also help reduce jaw joint pain.
JAW JOINT PAIN
It is possible to experience some pain or pressure in or around your jaw joint after jaw surgery. This may feel somewhat like an earache. This pain or pressure will usually disappear within 2 to 3 weeks. If the pain medication is not taking the pain away, let Dr. Trimble know and an anti-inflammatory medication may be prescribed. The new position of your jaw is the cause of pressure in the jaw joint area.
Since jaw surgery causes soreness in the muscles and bones of your face, you will find some difficulty in moving your jaw normally after surgery. We do not recommend any specific exercises during the first week or ten days after your surgery. Simply attempting to move your jaw side to side and opening slightly when you have your elastics off may help increase your jaw movement.
TEN DAYS TO FOUR WEEKS AFTER SURGERY
During the ten day to four week period after surgery, stand in front of the mirror and open and close your jaw 3-4 times a day when your elastics are off. A good time to do this is after you have eaten and cleaned your mouth. At this point you should be able to get one finger in between your teeth. By four weeks after surgery you should be able to get two fingers in between your teeth. DO NOT USE FINGER PRESSURE ON YOUR TEETH TO HELP STRETCH YOUR JAW OPENING AT THIS TIME. Your jaw is weakest ten days following your surgery. Simply move your jaw forward and backward, and side to side, and open and close, while attempting to stretch your jaw muscles. Moist heat placed on the side of your face before and during these exercises may make them more comfortable and effective.
FOUR TO EIGHT WEEKS AFTER SURGERY
During the fourth to eight weeks after surgery, you should be able to get two fingers between your front teeth very comfortably. Near the eighth week, you should be able to approach placing three fingers between the front teeth. At the sixth week you can begin using GENTLE finger pressure between the front teeth on each side to help gently stretch your jaw muscles, increasing your opening.
As with any surgical wound, it is extremely important for you to keep all areas inside your mouth clean after surgery. You should brush your teeth and rinse your mouth each time after you eat. Since you will most likely be eating small meals five or six times a day, you will need to clean your teeth at each of these intervals. Rinse with warm salt water (1 tsp salt in a warm glass of water) four times a day. Rinse with 1/2 warm salt water and 1/2 hydrogen peroxide once a day to help clean the wounds. Brush your teeth as usual, although it may be necessary to brush more frequently initially. The incision sites are above the gumline so brushing your teeth will not be a problem. Do not use a waterpick! Also brush your splint when doing your oral hygiene. It may be soaked in a denture cleanser if necessary. Unless otherwise instructed, your splint and elastics should be worn at all times, except while eating and completing your oral hygiene.
During the first week after surgery, be careful to make sure that while brushing your teeth the bristles of the brush stay on or very near the teeth and braces. You may have some soreness and difficulty opening your mouth, which may prevent you from brushing the inside of your teeth. This probably will improve with time and you should be able to accomplish this without difficulty within the first week to ten days after surgery. A small toothbrush will help make oral hygiene less difficult.
REMEMBER: The importance of cleaning your teeth and mouth cannot be overemphasized. This must be done several times each day to keep the mouth and incision sites clean. This will help the wounds heal quickly without getting an infection.
In the past, but very unusual at the present time, teeth were wired together after jaw surgery. This allows the bones to heal while they are being held still. In the majority of cases today, we use small bone plates and screws to hold the bones still to assist in healing. Support is also given by the splint and elastic traction. This allows the jaw to move and function during the healing period of 8-12 weeks. It must be remembered, however, that the bones are not completely healed and are being stabilized only by the screws and plates. Therefore, we encourage a gradual progression of movement and use of the jaws, keeping in mind that adequate healing does not take place until approximately 8-12 weeks. REMEMBER: Your jaws are weakest at 10 days.
Initially, it will be difficult to eat adequate amounts of food in only three meals per day. Try to eat five or six times a day, eating smaller portions each time. The following guidelines may be of help to you:
IMMEDIATELY FOLLOWING SURGERY TO DAY 10:
During this period the diet should be essentially non-chewing. This will minimize the stress on the plates and screws. This may consist of either blenderized food or fluids that don't require chewing. This can include soups, milkshakes, baby food, or any blenderized food. Some sort of diet supplement such as Ensure, Sustecal or similar substitute may be used once or twice a day to increase calorie intake. Plenty of clear fluids, water, etc. will help clean the thicker fluids from your mouth and throat. REMEMBER: It is very important to eat as much as possible to help your wounds heal properly.
DAY 10 TO DAY 28 AFTER SURGERY:
Food during this period does not need to be liquid. It can consist of soft foods that require minimal chewing. This can consist of mashed potatoes, scrambled eggs, soft pasta that is cut into small pieces, soft rice dishes, or soft sandwiches that are cut into small pieces. One can also eat the foods that were eaten during the initial period. Chewing can start during this period of time.
4 WEEKS TO 8 WEEKS AFTER SURGERY
At this point, chewing can be attempted. The food must be initially soft, progressing into softer meats such as hamburger and soft chicken. The portions should be small so as not to place too much force on the healing bones. Soft fish dishes are also excellent. You will find that your jaw will tire easily. This will continue for the first 2-3 months until your jaw muscles have accommodated for your new jaw position. Avoid eating food which requires chewing for prolonged periods of time.
RETURNING TO WORK
It will typically take 7-10 days of recovery before returning to work or school. This period may be shorter or longer in certain cases. You feel somewhat tired after your jaw surgery initially, but with good nutrition your energy level will soon return to normal. REMEMBER: IT TAKES 6 TO 8 WEEKS FOR INITIAL HEALING OF YOUR JAW OR JAWS AND 3 TO 4 MONTHS FOR A FULL BODY HEALING. If the jaw is hit or bumped early after your surgery, this may cause some shifting in the jaw and bite, SO BE CAREFUL!
You can resume light physical exercise as soon as you feel able following your surgery. The plastic splint should be worn at all times during exercise for the first 4-6 weeks after your jaw surgery. You should NOT participate in any exercise or sports that may involve hitting your jaw. These will include ALL CONTACT SPORTS, ANY SPORT INVOLVING A BALL, OR OTHER AGGRESSIVE SPORTS. You can resume light aerobic exercise, swimming, or running, as soon as you are able. Do not clench or stress your jaw muscles with heavy lifting or activity.
If you have had a bone graft from your hip area then you should resume any physical activity slowly and carefully. It may take 2-4 weeks before the hip area feels comfortable with exercise
It is normal to experience some bleeding from the mouth for the first 7-10 days after jaw surgery. This should not, however, be excessive. It will usually stop within a few minutes. With upper jaw surgery you may experience some old blood from the nose for the first week after surgery. This will usually happen as you stand or bend over. If bleeding is more than just a slow oozing, go immediately to the nearest emergency room and have them contact Dr. Trimble. This, by the way, is very rare.
X-rays will be required after your surgery. These will be typically done within the first few days after your surgery, then at three months, six months, and one year.
We hope that these postoperative instructions have been helpful for you. We encourage all patients to read these instructions at least once prior to surgery and keep them on hand for reference during the first week after their surgical procedure. We would also encourage family and friends who are involved in your care to read these instructions as this will help them make educated decisions regarding your care. Please contact our office at any time with questions that are not clarified in this pamphlet.