Orthognathic Surgery

This is a fundamental overview of what you might expect during your surgical orthognathic experience. We have tried to make this as comprehensive as possible so that you should are knowledgeable of what you might encounter during your surgery.

Please read all documents that were provided to you in the jaw surgery package folder so that you are familiar with the procedure, postoperative care, and management.

Orthognathic (Jaw) Surgery is a significant operation that requires the full participation of the patient and/or legal guardian(s). Therefore, the patient must fully educate themselves with the information package provided and ask questions with respect to the surgery or care. In addition, patients must have realistic expectations with respect to recovery, healing, and outcomes.   This is not minor surgery and requires significant recovery of at least 6 weeks.  That means reduced physical activities and attention to recovery and post-surgical management.  Also, one needs to expect some degree of pain, functional impairment, and significant swelling, in the short term, post-surgery.  This is a normal post-surgery course.

The day before surgery

1. No solid food after 6:00 p.m.
2. Clear liquid fluids only from 6:00 p.m. to midnight
3. No oral intake of any kind after midnight.

Following discharge from hospital, you will be required to have a responsible adult with you 2 weeks post-surgery. It is a matter of safety and support that you have an individual assist you while you are in elastic intermaxillary fixation. Please coordinate this prior to being admitted to hospital

If you are an out-of-town patient, you will be required to stay in Edmonton 2 weeks post-surgery for safety and support reasons. Please coordinate this prior to being admitted to hospital.

You will need to purchase a WaterPik® Water Flosser that you will need to be utilizing prior to your surgery and after your surgery. This will be utilized to maintain excellent oral hygiene. I strongly suggest that you mix 10% LISTERINE® with 90% water and wash all orthodontic brackets (braces) prior to your surgery, after your surgery, and after you eat. Only have the spray contact the teeth and brackets, do not spray the WaterPik® Water Flosser into the surgical wounds, either on the top jaw, bottom jaw, or chin area, depending on where your surgery was completed. Excellent oral hygiene is a necessity.

The morning of your surgery, you will need to brush, floss, use your WaterPik®, and rinse with mouthwash. Your oral cavity must be completely clean to reduce the potential for infection.

ADMISSION TO THE HOSPITAL

Prior to admission to the Royal Alexandra Hospital, you will be required to complete an examination by a Medical Doctor and a visit to the Pre-admission Clinic at the Hospital. Pediatric patients (<18 years old) are usually seen at the Stollery Children’s Health Centre Pre-admission Clinic (need for pre-admission clinic depends upon your medical status). A review of your medical history and appropriate tests will be completed. On the day of your surgery, you will be required to register into the hospital and they will direct you what to do while you await your surgery.

LENGTH OF THE SURGERY/HOSPITAL STAY

Surgeries can last anywhere from one to five hours, depending on the amount and type of surgery to be done. You can expect to stay in the hospital for one to two postoperative days. Depending on hospital policy, one of your family members may be able to stay in the hospital room with you the first night following surgery. This may make you feel more secure and comforted. Please inquire about this on hospital admission.

Following discharge from hospital, you will be required to have a responsible adult with you 2 weeks post-surgery. It is a matter of safety and support that you have an individual assist you while you are in elastic intermaxillary fixation. Please coordinate this prior to being admitted to hospital.

If you are an out-of-town patient, you will be required to stay in Edmonton 2 weeks post-surgery for safety and support reasons. Please coordinate this prior to being admitted to hospital.

RECOVERY ROOM/POST-ANESTHESIA CARE UNIT

You will be taken to the recovery room (PACU) immediately after surgery to safely regain consciousness from anesthesia and receive postoperative care. The recovery room nursing staff will work to ease your anxiety and ensure you have physical and emotional comfort. The amount of time each patient requires in the recovery room does vary by surgical procedure and the type of anesthesia used. After the effects of anesthesia have worn off completely and your condition is considered stable, you will be returned to your hospital room.

It is very common to wake up with your teeth fixated together with either tight or loose elastics. These are used to guide your jaws into their new position. There may be a splint (plastic bite plate) between your teeth to maintain your new bite. Nasal tubes are normally used with all surgical procedures done using general anesthesia; one leads to your stomach (nasogastric) and the other, to your lungs (endotracheal). Commonly, these tubes are removed just as you are “waking up” from anesthesia so you may or may not remember them. IV antibiotics, fluids, and medication will be given to you.

INTENSIVE CARE UNIT/ICU ADMISSION MAY OCCUR POST-SURGERY

ICU admission following major surgery is considered a standard of care for high-risk patients and those having complex or emergency surgery and is a precautionary measure following certain surgeries. ICUs are distinguished from general hospital wards by a higher staff-to-patient ratio and access to advanced medical resources and equipment that is not routinely available elsewhere.

POST-SURGERY

A nasogastric (NG) tube may be required and will be inserted through your nose. It is placed in the stomach to prevent nausea for a few hours following surgery. If you vomit, it will be in liquid form and the fluid can be expelled around the back of the teeth and through the braces. The nurse will suction any remaining fluid from your mouth or nose as you will not be allowed to spit. The nurse will also teach you how to suction yourself.

An IV will be present to replace your fluids, administer antibiotics and pain medications. This will be removed when you are able to get enough nutrition through syringe feedings.

Teeth may be fixated together with either tight or loose elastics, which is called maxillomandibular fixation. Elastics will be used at the time of surgery and it will be necessary for you to learn how to apply and remove them. You will need to replace any lost elastics to ensure the best outcome from your surgery. You will be required to carry small scissors or small pocketknife on you at all times in order to replace any elastics. The period of maxillomandibular fixation varies depending on your particular type of surgery but is usually required for approximately 1 to 4 weeks. This is a key to success in order to maintain your new jaw relationship. It is extremely important that you maintain proper care of your teeth while undergoing maxillomandibular fixation. When the fixation is removed, you may initially experience jaw muscle stiffness and limited jaw movement. This will resolve with exercise of these muscles.

Immediately following surgery, I recommend that you attempt to drink iced water to help settle your stomach. DO NOT USE A STRAW. DO NOT SWISH. Use the provided syringe to spray the teeth and brackets.

There will be swelling (especially of the lips and cheeks) and perhaps bruising. Swelling will likely peak 48 to 72 hours after surgery and decrease from that point. Keeping your head elevated by resting in a recliner or sleeping with an extra pillow will help limit swelling. Using ice packs for the first 48 hours will also help limit swelling.

You may have minor bleeding from the mouth or nose for several days. Any significant persistent bright red bleeding should be reported to your doctor immediately.

If a bone graft was removed from your leg, hip, or rib area, a dressing will be covering this site. Your oral and maxillofacial surgeon will discuss with you the care of the dressing.

At the hospital you will be provided with nasal sprays if you have had upper jaw surgery. This will help with your nasal congestion and improve your nasal breathing. If you underwent upper jaw surgery, it is critical that you do not blow your nose or suck on straws for 6 weeks post-surgery. You will need to utilize the nasal sprays for nasal/sinus congestion only. If you have to sneeze, sneeze with your lips apart to prevent blowing air into your sinus.

Your nose may feel congested after surgery. Do not blow your nose for 6 weeks, as this increases the pressure in the surgical site, which will lead to pain and bleeding. Congestion is usually at its peak usually between day 3 and 5 and may be present for 2 to 3 weeks post-surgery. You can take Otrivin, Sudafed, and saline spray to help alleviate this and it may be beneficial to use a vaporizer in your room.

At first, you may have difficulty communicating and may want to bring a small notebook to write your messages.

You may experience altered sensations or partial numbness. This is normal. During the first three to six months, the small nerve fibers are regenerating and mending. As healing takes place, you may encounter sensations of warmth and tingling in the affected areas. It is infrequent that these remain longer than 18 to 24 months; however, those individuals with small areas of residual altered sensations find they are able to adjust to them.

It is expected that you will need pain medication for a few days following your orthognathic surgery. This will be administered through your IV along with IV fluids, steroids, and antibiotics as needed. Your surgeon will also provide you with a prescription for pain medication to take after being discharged from hospital. If you are not experiencing any pain, then you do not need to take the medication. Tapering down on your medication is also encouraged. Any medications prescribed thereafter will be in liquid form.

It is critical that you constantly place ice on your face 24/7 for the first 2 weeks. This will reduce swelling faster and reduce your pain. Once we remove your intermaxillary fixation (elastics) after 2 weeks of healing, we will start you on home a physiotherapy program. At that time, I will recommend warm, moist, heat massages, and slow progression to a soft diet.  Drinking fluids post-surgery are absolutely essential. You MUST drink at least 3 to 4 litres of fluid per day to maintain normal hydration. As stated above, I recommend that whenever you take any medications, you take it with a large glass of chocolate milk. If you are lactose intolerant, I recommend that you drink chocolate soymilk.

It is normal to have reduced range of motion for a short period of time following your orthognathic (jaw) surgery. It typically takes approximately 3 to 6 months to get your range of motion back to normal. You might experience facial pain and tenderness while re-establishing your opening and closing. This is completely normal. On occasion, if you do not establish an adequate range of motion within 6 weeks following surgery, we may have to send you for postoperative physiotherapy.

Regarding facial swelling, approximately 60% of your swelling will be gone after 6 weeks post-surgery, 80% after 10 weeks post-surgery, and the last 5% to 10% of swelling will be gone between 6 to 12 months post-surgery. It is totally normal to take up to one year for the soft and hard tissues to settle and remodel before you have your final bite and facial appearance. You may experience numbness of your upper gums and lower lips/chin. This is absolutely normal post-surgery. It typically takes 3 to 18 months to recover, depending on your age and degree of surgical movement of your jaws. The chance of permanent numbness of your lower lip, jaw, and chin is approximately 1% to 2%.

At first, you will not be allowed to eat anything and this usually lasts until the nasogastric tube comes out (usually less than one day). Your diet will be progressed to a high calorie, high protein blenderized diet. You will be shown how to feed yourself with a syringe. Do not use a straw.  Good nutrition is critical for healing. The liquid/blenderized diet will be required for up to four to six weeks after your surgery.

You will need to do mouth rinses with special mouth rinses ordered by the doctor every two hours after eating to help decrease swelling and prevent infection. You can use a Monoject™ syringe or Waterpik® Water Flosser on low setting taking care to only use on teeth and not surgical sites. No swishing for 6 weeks.

Following your surgery, you may lose as much as 10% of your body weight. It is important to maintain a proper diet. You may be advised to supplement your diet with liquid vitamins and minerals. A blender can be used to liquefy almost any food to provide a balanced diet and there are other options such as BOOST® or Ensure®. Dietary intake is critical. Your tissues will be in a state of healing and your nutritional requirements need to be met. A dietician can be requested at the hospital to address any of your questions.

Almost all patients has some degree of facial asymmetry prior to surgery and it is also not uncommon to have asymmetrical swelling they may give the impression of an asymmetry but will resolve overtime. No one is 100% perfectly symmetrical either prior to or after jaw surgery.

Essential nutrients must all be present to promote complete soft tissue healing and a bony union at the surgical site. Calcium, Iron, Vitamins A, C, and D, and protein will be especially important in your diet. At times, you may not feel like eating, but please remember that good healing requires a sufficient dietary intake. A blender may be used to puree almost any food. Fruit and raw eggs are excellent nutritional additions to milkshakes. Experiment with a variety of foods.

You will need to always carry a small pocketknife or small scissors with you at all times in case of an emergency. In an emergency such as any breathing/air way issues, bleeding, severe panic attacks, anxiety, or if you become unconscious you must have someone cut the elastics holding your teeth together. If this is medical emergency also call 911. If the elastics are cut off and you are stable, call us at Edmonton Office Phone Number 780-454-6565 for further instructions.

Upon discharge from hospital, you are restricted in activities. You are not allowed to do any heavy lifting, exercises, working out, running, gardening or strenuous activities for 6 weeks post-surgery. If you have had upper jaw surgery completed, please do not bend over and stay upright, as this may cause nosebleeds.

Orthognathic (Jaw) Surgery is a significant operation that requires the full participation of the patient and/or legal guardian(s). Therefore, the patient must fully educate themselves with the information package provided and ask questions with respect to the surgery or care. In addition, patients must have realistic expectations with respect to recovery, healing, and outcomes.   This is not minor surgery and requires significant recovery of at least 6 weeks.  That means reduced physical activities and attention to recovery and post-surgical management.  Also, one needs to expect some degree of pain, functional impairment, and significant swelling, in the short term, post-surgery.  This is a normal post-surgery course.

SELF CARE/MENTAL ATTITUDE

Following any kind of surgery, a patient may go through a stage of mild depression. This is sometimes associated with steroid medication given to minimize swelling. A slight mood-elevating effect is associated with this drug. Therefore, as the drug leaves your system, you may experience a form of depression (usually on the third day). This is a natural response. We feel that if you are aware of the potential from the start, you will work at minimizing this by keeping your mind and body active. By the fourth and fifth day, you should return to good spirits. A very important factor in the success of your surgery is your mental attitude. There has been much interest in the effect of attitude on one’s overall health and healing. Positivity, laughter, and good feelings are known to cause the release of neurotransmitters (messengers) in the brain, which have a widespread effect on many biochemical processes taking place throughout your whole body. We do encourage a very positive mental attitude to promote good healing and a speedy recovery. Support from your family members and close friends is essential.

Patients need to have a clear understanding that this is major surgery, and you must have realistic expectations with respect to recovery, healing and returning to normal activities. Most patient feel better after 6 weeks but an appropriate time for complete healing takes a full year. Over this year you may still see changes to the bone, soft tissue, and teeth, these are normal changes that do occur.

FOLLOWUP

We will need to see you approximately 1 to 2 weeks after discharge from hospital for the next 6 to 8 weeks for observation. Once we are satisfied with your surgical stability, your recall visits will be less frequent. You may be in tight elastics for 1 to 4 weeks followed by guiding elastics. Once you are able to establish a good range of motion, you will then be referred back to your orthodontist for finishing orthodontic therapy and long-term retention.

YOUR RETURN TO WORK OR SCHOOL

You are encouraged to return to school or work as soon as you feel up to it. Some patients usually return to their regular activities as early as two weeks after their surgery. By four weeks, you should have adequately regained your strength.

DENTAL HYGIENE

During dental fixation, oral hygiene will be more difficult. You will be unable to clear the tongue side of your teeth. It is therefore essential for you to make an effort in applying the following recommendations. You must brush your teeth as thoroughly as possible. A child’s size soft toothbrush is more efficient. Since your cheeks may become swollen, the smaller the toothbrush head permits easier access.

A toothpick device called the Perio-Aide is a helpful adjunct to tooth brushing, since flossing your teeth will be impossible. Perio-Aides facilitate cleaning along the gum line. These come with instructions and can be found in most drug stores. Proxy brushes are also good for cleaning and are used similarly to Perio-Aides. If you keep your teeth relatively free of food debris, you will feel more tolerant of the wires and elastics. Use the Water-Pik™ Water Flosser on low setting on teeth only for 4 weeks after surgery as food debris could be forced through the incision sites and lead to infection.

TOOTH VITALITY

With orthognathic surgery and other surgical procedures, there is a risk that a tooth can become devitalized. This can most likely be resolved with endodontic (root canal) treatment.

If you have any unanswered questions, we will be happy to clarify any of this information for you. We want to make your hospital stay and the subsequent weeks as pleasant as possible. Please let us know so that we can address all of your questions and concerns prior to your surgical procedure.