PHASE I - IMMEDIATELY BEFORE AND AFTER SURGERY Prior to your jaw surgery, you will visit your surgeon to have molds and records taken. This office appointment can vary between 1 to 2 hours in length. It will consist of taking x-rays, molds and photographs and is an opportunity for you to sit down with all your remaining questions. It's also an opportune moment for any family member(s) that may be with you to also discuss with your surgeon the period following the surgery.
Prior to your surgery, it is imperative that you have seen the orthodontist for placement of surgical hooks and your family dentist for a generalized cleaning since oral hygiene will be a little difficult for the first 2 weeks. Also, you should enjoy a normal routine and savor your favorite meals, since these will be curtailed for at least 1 month after surgery.
The day and morning before your surgery, it is important that you thoroughly brush all your teeth and appliances.
The day of your surgery, you will first meet the anesthetist who will bring you to the operating room and guide you through the process over the next few hours. Depending on the number of jaws that you will have surgery on, the length will vary between 1 to 3 hours. This is different for all patients and this will be explained to you.
When you wake up from your surgery, your teeth may be held together with small elastics, just to help you guide into your new occlusion. These elastics, if present, will be changed after the first week.
You will be completely numb on the jaw that was operated on, so there is not a great amount of pain. However, the swelling starts up immediately and there is some jaw stiffness to be anticipated. There is some soreness from the breathing tube that the anesthetist places and this soreness will also subside with time.
Your course in hospital will usually last 1 night for 1 jaw and 2 nights for 2 or more jaws. The goal of your hospital stay is to ensure that you are drinking as best as you can. We will be coaching you to do some walking around, but drinking is of the highest necessity. Too much activity may cause a bit of nausea, so it's best to remain as quiet as possible.
Immediately After Surgery
- All patients feel discomfort or pain after an operation, although the level of pain varies from patient to patient. Take your pain medications as directed.
- When you go home, it is important that a friend or relative spends the first night with you. Continue to take any previous medications before following the instructions on the bottle.
- You will be able to shower on the second day after surgery. You must avoid hot, prolonged showers which may cause bleeding in the upper jaw if surgery is performed there.
- Avoid exercises, any heavy lifting or activity that raises your blood pressure or pulse for at least one month after the surgery. The blood vessels are still healing from the surgery and any increase in activity may cause bleeding. You may begin gentle exercise after 2 weeks, but do not do any cardio for 4 weeks after the surgery.
- Do not drive a vehicle or perform any task that requires coordination or judgment for at least 48 hours following your anesthetic.
You will be provided with prescriptions for the following medications:
- Celebrex 200mg orally 2 times a day for 14 days. This is to help decrease your swelling and help control pain. This is a small white pill which you will need to swallow with some fluid.
- Codeine Elixir 30mg will be given to you in a syrup form and you will take this every 4 or 6 hours as you need for pain. You will most likely need it the first 2-3 days.
- Amoxicillin 500mg Elixir - you will take this 3 times a day for 7 days and this prescription is an antibiotic that must be finished. If you are penicillin allergic, you will be given another antibiotic.
- Ativan 1mg tablet that you will place either in your cheek pouch or underneath your tongue and this is to help you sleep at night without causing any undue clenching or grinding that sometimes occurs. You will be given 14 tablets. You are encouraged to use this for at least the first 7 days and then if needed after that.
Immediately after surgery, you will need to stay on a clear liquid diet to ensure that the wounds do not get burdened with debris. A suggestion is the following:
- The first 5 days will be clear fluids; that is anything you can see through, from Gatorade, clear soft drinks, clear soups, Jell-O.
- 5 days after that, you can move onto any liquid including milk shakes, ice cream, Soya milk drinks, yogurts, soft cheeses, protein drinks and protein supplements as well as nutritional supplements (such as Ensure, Boost, Whey, protein powders, tofu);
- 5 days after that, you can commence a soft food diet. A recommendation is to eat anything that does not make any noise, therefore hard or crunchy foods must be avoided. Most foods will be satisfactory at this stage including pastas, rice, potatoes, etc.
There is no limit to what you should eat, as long as you don't need to chew too vigorously. This is all that really should be taken by mouth for the first week.
The amount of swelling that will take place in your cheeks will make it very difficult to brush your teeth. In fact, you should not brush your teeth for 1 full week after surgery, otherwise the incisions can be damaged and bleeding may start. You should use warm saline rinses (1/2 teaspoon salt in a tumbler of warm water). You can rinse your mouth with salt water as often as you would like, even up to every 2 hours. You cannot do enough rinses. This will keep your mouth nice and clean and will also tend to shrink the incision lines inside the mouth. Your hygiene will change into the second phase. You may also be given a prescription for Peridex, an anti-bacterial mouth rinse. If that is given to you, use it as prescribed.
The swelling is perhaps the greatest post-operative event of your jaw surgery. This will vary from patient to patient. You must anticipate a large degree of swelling over your cheek area as well as down into your neck. The swelling is maximal at Day 4 and will slowly subside after 2 weeks. There is still about 10 to 20% of swelling that can maintain up to 2 months after surgery. You should only be critical of the result about 3 months after surgery. You will have been given medications during the surgery and immediately after to help settle down some of the swelling, but once it has occurred on Day 3, there is very little that can be done to eliminate it.
You should place ice on your face while you're awake for the first 3 to 4 days. The ice will also have a numbing effect that will reduce any post-operative sensitivity. You must be careful not to apply too much ice directly on the skin, as it may cause burns. After Day 4, a warm water bottle is then recommended to help reduce swelling.
Bruising is also quite normal after jaw surgery. Depending on which jaw was operated on, you may have bruising in the area of your upper cheek and eyes as well as your lower cheeks and down into your neck. It is not unusual to have some bruising extend all the way onto your chest. The bruising is unsightly and disconcerting, but you must understand it is perfectly normal and should not be of any concern. It will go away after about 2 weeks.
You should maintain minimal activity within the first week. You are able to walk and move about but you should not do any exercises, jogging or weight lifting, regardless of how well you feel. You will have lost some blood during the operation and you may be feeling weak or faint. This is not the time to try to get back into shape. It will take one month before you fully recover from the amount of blood loss and strength due to your surgery.
You may have some altered sensation to your hearing due to some of the swelling extending into the area of the ear. This numbness or muffled sound is not unusual and you should expect some of it. You may also experience some joint noises on the right and left hand side. Your joints need to get accustomed to their new position.
You will need to call the office for a follow-up visit between 4 and 7 days post-op. Please make this yourself once you get home.
Your surgeon will give you a handout regarding the second phase of healing once you are ready. Until then relax, take the medications, drink as best as you can and call if there are any problems - 416-752-52222.
PHASE II - 1 TO 4 WEEKS AFTER SURGERY
In this phase, the majority of swelling and bruising will have peaked and are starting to subside. It is now a time to get your jaws actively working again so that you can resume normal activity. There are a few points to remember and a few changes:
Depending on the amount of mouth opening you have and also the amount of elastics that may be placed, your diet will be still restricted to your mouth opening. However, you can now start moving up to a more substantial diet. A shopping list for the second to fourth week would include the following:
- Continuation of Phase I liquids;
- Dairy products: continue with milk shakes, ice cream, soya milk drinks, yogurts, soft cheeses;
- Protein drinks and protein supplements as well as nutritional supplements (such as Ensure, Boost, Whey, protein powders, tofu);
- Egg products (scrambled, boiled, omelettes, ...);
- Pureed vegetables and meats of a similar consistency to baby food. (this would include potatoes, peas, carrots);
- Starches such as mashed potatoes, rice and pasta;
- Other proteins such as minced meat and white fish.
Again, there is no limit as to the amount you should eat and in fact you should try to now increase your nutritional intake, since there may have been some weight loss initially and now your body is demanding extra nutrition during this healing phase. Once again, it is imperative that you do not actively chew and you should avoid anything at all that is hard, including tough meats, candies, popcorn, pretzels, peanuts and other nuts.
Now that the swelling is slowly starting to subside, you'll be able to get into the mouth and cheek areas a little bit more easily. You should purchase a new toothbrush and, using a small amount of toothpaste, concentrate on brushing the metal braces. You should spend at least 15-20 minutes in the evening prior to going to bed to do a thorough cleaning of all the teeth and brackets. Not only will this make you feel a little better, it will also help reduce any swelling around the gums and cheeks. Continue rinsing your mouth with salt water at least twice a day, but be careful not to injure the wounds with the head of the toothbrush. If you do hit the wounds, there may be a little bleeding, but this is normal and should not cause any worry.
The swelling will now begin to subside and by the second and third week, the majority of it will be gone, but remember, there's still about 10 to 20% that can maintain up to 2 months. Ice will no longer help reduce the swelling; you may want to switch to using warm water bottles over the area. However, this will go down on its own.
Bruising may still maintain into the second week, as far down as into the neck and chest areas. Although this is unsightly, it is perfectly normal and will go away.
You will still be feeling slightly weak due to the surgery itself and the minor blood loss. You can start a regular routine of physical exercise that you may have had prior to surgery, but you should still avoid any heavy running or activities that will produce too much motion in the head and neck areas. Simple walking and stairs and mild activity is encouraged and will help with the elimination of some swelling.
The joints on the right and left-hand sides near your ears may now be functioning a little bit more, but due to the jaw surgery, will find themselves in a new position. It is not unusual to hear some noises such as clicking or popping of the joint as you start to function more and more. These joint noises and discomforts will continue up until about 6 weeks post-surgery.
If you've had upper jaw surgery, the numbness tends to be reduced in the upper lip and jaw area and this is first felt as an itchy or pins and needles sensation. In the lower lip area, there will still be some numbness and pins and needles at least up until 6 months after surgery.
If you've had upper jaw surgery, a nasal discharge of a red-brown fluid may occur. This is normal and is a product of the blood clots being dissolved just behind the upper jaw. If you should experience brisk bright red blood that is not controlled with pressure on the nose, please contact the office.
- Facial Reanimation
What I would like for you to do during the initial phases and up to a month after surgery are lip and cheek exercises. This produces strengthening of the muscles in and around the area of the mouth and nose, reduces swelling in the area and will also bring the life back to that area of your face. These exercises are quite simple and they consist of grimacing, pulling your lips apart, putting a pencil between your lips and trying to squeeze the pencil, smiling and all types of movements of the lips, cheeks and chin.
- Joint Exercises
This consists of exercises of opening and closing the jaw. For the first 2 weeks, your goal should be to open your teeth apart approximately 2 finger breadths. This consists of placing some warm packs over the right and left-hand side and gently massaging the joints on both sides and then slowly and passively opening the jaw as much as you can. By 3 to 4 weeks post-operative, your goal should be to open approximately 3 finger breadths. This is an area that will be actively encouraged during your post-op therapy.
Your appointments will now continue probably every 2 weeks. The antibiotics will have been terminated at this stage. If you need medications to help you sleep through the night, just speak to your doctor. Oftentimes, you may find yourself clenching and grinding your teeth in the middle of the night; this is not unusual, but if it is disturbing to you, we can give you something to help you through this. Your final phase will be from approximately 4 to 6 weeks after the surgery until you have your braces removed. This phase will be explained to you at the appropriate time.