WILLIAM R. McDONALD, D.M.D., M.D., F.R.C.D.(C)
ORAL AND MAXILLOFACIAL SURGERY
#705-805 WEST BROADWAY VANCOUVER B.C. V5Z 1K1 604-873-0303


Post Operative Instructions After Orthognathic (Jaw) Surgery

After you have undergone a surgical procedure to reposition your upper jaw, lower jaw, or both, attention must be given to several aspects of postoperative care, in order to help make the recovery as quick and easy as possible.

Since surgery produces soreness in the muscles and bones of the jaw, as well as the lips, nose and other areas of the face, some difficulty can be encountered in performing such tasks as eating, drinking, and cleaning your teeth. Each of these things must be done continuously and carefully to avoid postoperative problems. The following is a list of instructions which should help you in your postoperative recovery.

DRINKING

Following jaw surgery there is frequently some numbness in the upper or lower lip, or both lips. When this is combined with facial swelling and soreness, due to incisions inside the mouth, a task as basic as drinking may seem somewhat difficult. There are several tips which may help you:

(1) Attempt to drink from a cup if possible. While some fluid may be spilled when drinking in this manner, this is still the most effective way of taking fluids.

(2) Place a towel under your chin if necessary and place a small amount of fluid in your cup. Tip your head back slightly and attempt to open your mouth a tiny bit 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.

(3) You should be drinking a fair amount of fluid after jaw surgery. Daily amounts should be between 2 to 3 liters. Fruit juices are an excellent source of fluid, especially apple juice.

(4) If you experience continued difficulty with drinking from a cup then the alternatives are: - Using a straw to help put fluid into your mouth. One should not attempt to suck too hard on the straw, as this may start the surgical wounds bleeding. One can also use a syringe with a rubber extender and inject the fluid into the mouth, between the molar teeth and the cheek. REMEMBER: Taking adequate amounts of fluids is essential following surgery. This can consist of fruit juices, milk or water.

EATING

In the past, and occasionally at the present time, teeth must be 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 while allowing them to heal. This allows the jaws to move and function somewhat during the healing period of 8 to 12 weeks.

Today, in most cases, the jaws are wired for only the first one or two days while you are in hospital. It must be remember however, that the bones are not healed and are simply being held together 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 to 12 weeks.

In order to eat following surgery the following may be helpful;

(1) 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.

(2) Remove the rubber bands and plastic splint during eating. These should be replaced after eating and cleaning your teeth.

(3) Use the following guidelines for progressing along with your diet;

A. IMMEDIATELY FOLLOWING SURGERY TO DAY TEN
During this period the diet should be essentially non chewing. This may consist of either blenderized food or very soft foods that don't require much chewing. This can include soups, milkshakes, babyfood, 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.

REMEMBER: It is very important to eat a normal amount of food to help your wounds heal properly.

B. DAY 10 TO DAY 21 ( 3 WEEKS ) 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 but you still need to be careful.

C. THREE WEEKS TO SIX WEEKS AFTER SURGERY
At this point an increased amount of chewing can be attempted. The food must be initially soft and progressing into softer meats such as hamburger or 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 to 3 months until your jaw muscles have accommodated to your new jaw position. Avoid eating food which requires chewing for prolonged periods of time, on a single piece of food.

D. AFTER SIX WEEKS
Chewing can now commence on a more normal basis. However, remember that it will be a few more weeks until the jaw is completely healed and common sense dictates that food still be somewhat soft. Foods such as pizza, apples, tough meat, etc. should be avoided until at least three months after surgery.

ELASTICS

Usually some type of elastics or small rubber bands are used during the time immediately after surgery. These rubber bands are placed around small lugs or hooks on the braces or arch wires. The purpose of these elastics is to help train you to bite into the new jaw position and to limit jaw function.

There is a plastic splint sitting between the upper and lower teeth. This splint has small indentations which are made for each jaw to bite into. With the elastics in place and your teeth together, you should see that the teeth fit into the grooves in the splint. Instruction on how to change the elastics and remove the splint will be given during your office visit on the day you leave the hospital.

1.) The elastics should be worn at all times except when eating for the first two weeks. The plastic splint will also be worn during this period. The elastics should be placed in the same position as you were shown after you left the hospital.

2.) The elastics and plastic splint should be removed during eating, but should be replaced immediately after eating and cleaning your teeth. 3.) New elastics should be used each day as they will become stretched after being worn for a short period.

HYGIENE

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 after each time that 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.

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 may have some difficulty in opening your mouth. This may prevent you from brushing the tongue side of your teeth. This will improve in time and you should be able to accomplish this without difficulty within the first week to ten days after surgery.

The small toothbrush that you were given when you left the hospital will also help to brush the tongue side of your teeth.

1.) Each time you brush your teeth place a small amount of toothpaste on the toothbrush and brush all areas of the braces on top and bottom.

2.) Rinse your mouth thoroughly with warm salt water or mouthwash mixed with half water, half mouthwash. Also make sure you rinse the surgical incision sites with the syringe that you were given as you left the hospital. Salt water, plain tap water, or half mouthwash/half water can be used in the syringe.

3.) At seven days after your surgery you can begin using a water pik if you have one. DO NOT USE A WATER PIK INSIDE YOUR MOUTH FOR THE FIRST WEEK AFTER SURGERY AS THIS MAY DISTURB THE HEALING OF THE SURGICAL INCISIONS AND CREATE MORE BLEEDING. A low setting is recommended on the water pik.

4.) Occasionally with cleaning your teeth, you may get some bleeding from your mouth. This is to be expected during the first 1 to 2 weeks after your surgery. The bleeding should stop within minutes after you have finished cleaning your teeth. This is normal after mouth surgery during the first 1 to 2 weeks.

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, so that they can heal properly without getting an infection.

JAW OPENING

Since jaw surgery causes soreness in the muscles and bones of your jaw, you will find some difficulty in moving your jaw normally after surgery. We do not recommend any specific exercises during the first week to ten days after your surgery.

Simply attempting to move your jaw side to side and opening slightly, when you have your elastics off during eating, may help to increase your jaw movement.

TEN DAYS TO FOUR WEEKS AFTER SURGERY

Stand in front of a mirror and attempt to open and close your jaw as much as possible. 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.

Simply move your jaw forward and backward, side to side, and open and close, while attempting to increase your opening with your jaw muscles only. Moist heat placed on the side of your face before and during these exercises may make these more comfortable and effective.

FOUR TO EIGHT WEEKS AFTER SURGERY

During the fourth to eighth weeks after surgery you should be able to get two fingers in 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 fourth week you can begin using gentle finger pressure between the front teeth on each side to help gently stretch your jaw muscles, to increase your opening. This will be demonstrated to you, at your five week postsurgery visit, if your jaw opening is not within the normal range, for this time period.

SWELLING This will vary from person to person, and is a normal response to any surgery. You have been given a medication while in hospital and for the first few days at home to try and minimize the amount of swelling. Normally this lasts between two to three weeks.

A small amount of swelling can persist in some patients after this time and is usually due to immature bone formation at the surgical site. This will feel hard to the touch and will eventually disappear within 2 to 3 months. This results from too much new bone formation at the jaw surgery site, in some people. It is however normal healing.

To help minimize the amount of swelling you can;

1.) Place ice constantly over the surgical site for the first week after surgery.

2.) Wear the compressive bandage as much as possible for the first week after your surgery. This will only be given to lower jaw surgery patients as it has no effect on upper jaw surgery. This should be placed fairly tight over the face to apply pressure on the surgical site. It should never be placed so tight that it causes more pain.

3.) After the first week you can start to use warm moist heat over the surgical sites to help reduce the swelling. Ice will have no effect on swelling after the first week. One can use a hot water bottle to apply this heat.

4.) During the first week after surgery try and sleep with two pillows. This will keep your head elevated and limit the amount of fluid that is available for any swelling. If you do lie flat at night, you will find that the swelling will be increased when you awake. This will usually diminish as you assume an upright posture. ( sitting or standing )

BRUISING

This is normal after jaw surgery and will usually last about two to three weeks if it occurs. It may appear over the surgery site only, or it can be very widespread extending even down into the upper chest area. Application of moist heat (hot water bottle) after the first week following your surgery, may help to resolve the bruising

PLASTIC SPLINT

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 eating for the first two weeks after your surgery. It should be removed while you are eating.

You will be shown how to remove and replace it 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. After the first two weeks you can start to remove it as follows.

DURING THE THIRD WEEK AFTER SURGERY

The plastic splint can be removed on and off during the day but it should still be worn at night. If you have returned to work then you can leave it out while at work, as long as it feels comfortable without it. If there are only a few of your teeth touching when you bite after surgery,then it may feel more comfortable to wear the splint, as it will balance the bite properly.

AFTER THE THIRD WEEK

You can leave the splint out all the time as long as your bite feels comfortable. If you have trouble feeling where to bite or experience any pain while the splint is out, then the plastic splint should still be worn as much as possible. Once you get to the sixth week after your surgery your orthodontist can now start to finish the braces, and the splint will need to be removed at this time.

JAW JOINT PAIN

It is not uncommon to experience some pain or pressure in or around your jaw joint areas after jaw surgery. This may feel somewhat like an earache. It is due to pressure in the jaw joint area due to the new position of your jaw. This will usually disappear within 2 to 3 weeks. If the pain medication is not taking the pain away, let your surgeon know and an anti-inflammatory medication may be prescribed.

PHYSICAL EXERCISE

You can resume light physical exercise as soon as you are able following your surgery. The plastic splint should be worn at all times during exercise for the first 4 to 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, walking or running, as soon as you are able. You may swim as long as you have NO SURGICAL INCISIONS ON YOUR SKIN.

With surgical incisions on your skin, swimming should wait until at least 2 weeks after your surgery.

REMEMBER: Your jaw or jaws are not fully healed until 8 to 12 weeks after your surgery, so be very careful with sporting activities.

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 to 4 weeks before the hip area feels comfortable with exercise.

RETURNING TO WORK OR SCHOOL The usual recovery after jaw surgery is about 2 weeks. This may be either shorter or longer in certain cases. You may return to work or school as soon as you feel able after your surgery.

You will feel somewhat tired after your jaw surgery initially, but with good nutrition, your energy level will soon return to normal. One should be careful in certain jobs where there is a chance of your jaw or jaws getting hit or bumped soon after your surgery.

REMEMBER: It takes 6 to 8 weeks for initial healing of your jaw or jaws and 8 to 12 weeks for full bony healing. If the jaw is hit or bumped early after your surgery this may cause some shifting in the jaw or jaws and bite, resulting in another surgery to correct the shifting. So be CAREFUL.

MEDICATIONS

On leaving the hospital you will be given a prescription for any necessary medications. This will usually consist of a pain relieving medication, an anti-swelling medication, and an antibiotic. Please take them as described on the bottles or as directed by your surgeon. If you have any problems with the medications please contact your surgeon immediately.

BATHING OR SHOWERING

Jaw surgery usually involves surgical incisions that are in the mouth. If this is your case, then you can shower, take a bath, or shampoo your hair, immediately after your surgery, as soon as you feel like it.

Sometimes there are surgical incisions on the skin, either on the neck, or on the hip area if a bone graft is necessary. If this is your case, then you should NOT shower or take a bath for 7 to 10 days after your surgery. You can take a sponge bath to wipe your skin clean, being careful not to get the incision areas wet. Care must be taken when shampooing your hair, not to get any of the skin incisions wet. This to prevent an infection occurring in the incision area.

BLEEDING

It is normal to experience some bleeding from the mouth for the first 7 to 10 days after your jaw surgery. This should not however, be excessive. It will usually stop within minutes after it has started. With upper jaw surgery you may experience nose bleeds for the first week after surgery. This will usually happen as you stand.

Applying ice over the nose will usually help stop the bleeding. You may also have to squeeze your nostrils together to stop this bleeding.

YOUR NEW BITE

After your jaw surgery you may find that not all of your teeth touch when you bite them together. This will be corrected by your orthodontist during the postsurgical orthodontic phase. To fully correct your bite it will take anywhere from 6 to 18 months of braces following your jaw surgery. The jaw surgery places the jaws in proper alignment with each other, and the braces will line your teeth up in this new position.

BONE GRAFTS FROM THE HIP

If you have had a bone graft taken from your hip, then you will need to keep the incision area dry for 7 days after your surgery. This is necessary to avoid any infections in the incision area. After this time you may shower or bath the area as needed.

Initially the area will be sore when walking, however some movement is desired to help the area recover. This may last up to 2 or 3 weeks after the surgery. .. As you can see, recovery from jaw surgery requires a lot of effort on your part. We will be happy to answer any questions regarding diet, oral hygiene, elastics, exercise, or any problem which may be of concern to you.

Remember, postsurgical progress is sometimes uncomfortable, and may occur slowly. With some determination and attention to these instructions you will find that your postoperative recovery will occur as quickly as possible. You can contact Drs. McDonald OR Blankstein at the following numbers:

OFFICE NUMBER: 604-873-0303
PAGER NUMBER: 604-689-7243