Corrective Jaw Surgery

Overview

After you have undergone a surgical procedure to correct the position of 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 is encountered in performing such tasks as eating, drinking and cleaning your teeth. However, each of these things must be done continuously and carefully to avoid postoperative problems. This is a list of instructions which should help you in your postoperative recovery.

Immediate Post-Operative Instructions for Corrective Jaw Surgery

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Diet

For now, it is important you maintain a STRICT LIQUID DIET ONLY. The plates and screws used to secure the jaw(s) in their new position take 6 weeks to stabilize, and thus your diet will need to progress slowly. Do not use a straw for the first 48 hours after surgery as it can create more bleeding. Avoid cold milk products for 48 hours after surgery as it can adhere to the incision sites and may promote infections. Attempt to drink from a cup as soon as possible, as this is the most effective way to take in liquids. Sometimes the use of a toddler “sippy cup” can help. If drinking from a cup seems to be impossible, another alternative is to obtain a squeeze bottle to squirt fluid into your mouth. This type of device can be obtained at most department stores, sporting goods stores, or bicycle shops. Examples of nutrition that is safe to consume are:

• Protein shakes and smoothies
• Soup broth at a warm temperature
• Gatorade and water

PAIN MANAGEMENT

Baseline Pain Control Regimen

• 650 mg Tylenol (Acetaminophen) 2 x 325 mg tablets, or liquid equivalent, 4 times per day. Breakfast, lunch, dinner, and right before bed. (Avoid Tylenol if you have been told not to take this medication or have liver failure)
• 600 mg Advil (Ibuprofen) 3 x 200mg tablets, or liquid equivalent, 4 times per day. Breakfast lunch, dinner, and right before bed. (Avoid ibuprofen if you have been told not to take this medication or if you have a history of stomach ulcers or kidney disease)
• Healthy people who stay properly hydrated can maintain this baseline pain control regimen for up to 3 weeks without any side effects. It is extremely important to maintain hydration in the post-operative period. If you are still needing this pain control after 3 weeks notify your surgeon.

If Additional Pain Control is Needed

• 2.5 – 5 mg Oxycodone ½ – 1 x tablet, or liquid equivalent, up to 4 times per day if needed for additional pain control.
• Do not stop taking the baseline pain control regimen if you need the oxycodone

Pain Management Philosophy and Science

Postoperative pain control is of paramount importance to us and our patients after surgery. We want you to be as comfortable as possible as you recover from your surgery. When you return home and the local anesthesia (numbing medicine) wears off, you will transition to oral pain medications to assist in pain control. The goal of postoperative pain management is to use oral pain medications to reduce pain to a tolerable level while the body heals and reduces pain naturally overtime. This may result in a maximal oral medication regimen which can be progressively decreased over the recovery process. Modern medicine uses three common classes of medications to achieve this goal, Acetaminophen (e.g. Tylenol), Non-Steroidal Anti-Inflammatory Drugs (NSAID e.g. Ibuprofen/Advil), and opiates (e.g. Oxycodone). Each act on different pain pathways within the body which allows them to all work synergistically at the same time. Using different classes of pain medications allows us to maximize the potential benefits of any one class while minimizing their respective side effects. During the postoperative period we want to maximize your pain control while minimizing any potential side effects. All pain medicine should be used in an “as needed” fashion. If you are not in pain, you do not need to take pain medicine. However, the baseline pain control regimen outlined above can be more effective if taken on a “scheduled” basis, regularly spaced time intervals, during the postoperative period where significant pain is anticipated. The baseline pain control regimen is more effective if taken on a “scheduled” basis rather than waiting for significant pain before taking the pain medicine. This “scheduled” strategy allows you to maintain a constant level of pain control in your blood which ultimately results in more effective pain control. If you would like to take the baseline pain control regimen on a “scheduled” basis to maximize its effectiveness we recommend taking these medications ~ 4 times per day, convenient times for most patients are breakfast, lunch, dinner, and right before you go to bed. The baseline pain control regimen can be taken together as instructed above for up to 1 week without concern for significant side effects in a healthy patient. However, if you find yourself continuing to need a “scheduled” baseline pain control regimen after 1 week, please let us know so we can make sure that you are healing appropriately. Opiate derived pain medications, like oxycodone, have rightfully received a lot of attention in the media recently due to their addictive potential. While this class of medication can be addictive it is important to note that addiction occurs when these medications are used for prolonged durations for chronic pain, not for acute postoperative pain. As such, these medications are safe to use as prescribed for a short duration after your surgery. However, they have other side-effects as well such as nausea, constipation, and drowsiness which are undesirable. As a result, we still reserve this class of medication for as needed additional pain control if the baseline pain control regimen above is insufficient. We hope all our patients recover as painlessly as possible. However, recovering from surgery is typically uncomfortable. The strategies and philosophies outlined above will not make the recovery from surgery painless, but they should serve to reduce the pain to a tolerable level while the body heals and subsequently reduces pain naturally. If you ever feel that the pain is unbearable despite these medications, please let us know so we can make sure that you are healing appropriately.

PRESCRIPTION MEDICATIONS

In addition to the prescription for oxycodone you will be given several other prescription medications to aid in your recovery.

• Antibiotics: You will be given a prescription for an antibiotic such as amoxicillin or clindamycin, etc. This medication should be taken at the appropriate interval as described on the bottle. Be sure not to miss any doses and take the medicine until it is gone. Note: Some types of antibiotics reduce the contraceptive effects of birth control pills.
• Anti-Nausea Medicine: You will be given a prescription for Zofran (Ondansetron). If you are feeling nauseated after surgery this medication can be placed under the tongue. When placed under the tongue it will dissolve and be absorbed by your body. This medication should only be used if you are nauseous. It can be taken once every 6 hours if nausea persists.
• Mouth Wash: You will be given a prescription for Peridex (Chlorhexidine) which is a mouth wash that can help substitute for tooth brushing in the first week. Swish gently with ~15ml of this medication for 30 seconds and spit.

OVER-THE-COUNTER MEDICATIONS

Below are some medications available over the counter at any local pharmacy that may be helpful to aid in your recovery.

• Decongestants:: Following orthognathic surgery, especially upper jaw surgery, there is considerable stuffiness of the nose and sinuses. If a decongestant is recommended, take the medication as indicated on the bottle for seven to ten days or as needed for congestion. A decongestant such as Sudafed® is better for clearing up a runny nose while a decongestant such as Mucinex® (Maximum Strength or DM) will better aid with thinning excess mucus secretions and build up in the back of the throat. Note: During this time, keeping the head elevated with a pillow or two will aid with the flow of congestion and keep secretions from building up in the back of the throat overnight. This will make sleeping a little easier. Do not blow your nose for 10 days after you had upper jaw surgery.
• Nasal Spray: (Afrin®, Neosynephrine® or equivalent) can be used as six to eight hour intervals to help improve breathing through your nose. In order to prevent overuse of the nasal spray, this can be alternated with plain saline (salt water or ocean spray) nasal spray. These sprays can be purchased from your pharmacy.
• Lip Ointment: You will be given a tube of lip ointment at the hospital. Use this for the first two days. Keep enough ointment on the lips to keep them looking wet. After two days stop using the ointment and use plain Vaseline®.
• Stool Softener: Taking an opiate derived pain reliever like oxycodone will eventually cause constipation. You can take Miralax (or a generic version), a very effective stool softener, while you are taking oxycodone to avoid constipation. Take as directed on the bottle.

ORAL HYGIENE

Maintaining proper oral hygiene can be extremely difficult post-operatively, but it is incredibly important to help prevent an infection from developing. We recommend purchasing a baby toothbrush as the smaller size and soft bristles will make it easier to keep your braces and teeth clean. It is important you brush your teeth at least twice a day, taking care to clean the front of your teeth and braces only (do not clean the gums because your surgical incisions are in that area). You may also be prescribed an antibacterial mouth rinse (e.g. Chlorhexidine) that can be used twice a day to help clean and prevent infection. Do not use a water pik or electric toothbrush for the first 7 days after surgery.

SWELLING REDUCTION STRATEGY

• First 72 hours –Limit Swelling Accumulation
  1. Apply ice to limit accumulation of swelling. 20 minutes on and 20 minutes off while awake. (e.g. ice packs and head wrap provided, frozen peas/corn)
  2. Elastic facial dressing (jaw bra): This elastic bandage should be kept in place as much as possible for the first 24 hours without the ice if sleeping. After the first day, this bandage is not essential, but may help reduce swelling more quickly. Wearing this dressing at night will also help reduce swelling more quickly.
  3. Elevate your head while sleeping and resting by using several pillows such that your head is above your heart. This will help reduce swelling accumulation.
  4. Take NSAIDs (Ibuprofen/Advil) if instructed as part of the baseline pain control regimen above
• After 72 hours – Promote Resolution of Swelling
  1. Apply moist heat to promote drainage of swelling which has accumulated during initial healing phase. (e.g. clay heat packs sold in drug store, moist towel heated in microwave)
  2. Continuing to elevate your head while sleeping and resting by using several pillows such that your head is above your heart. This will improve swelling draining from the face.

Swelling Management Philosophy and Science

• Swelling is a natural part of your body’s healing process. During the early phases of recovery from surgery tiny vessels called capillaries become increasingly porous resulting in fluid escaping and accumulating in your tissues. This accumulation of fluid allows for your body’s healing machinery to access the injured area. However, this typically results in undesirable tension and a reduction in range of motion of muscles in the area. Both of these things can contribute to postoperative pain and discomfort which is why we attempt to reduce postoperative swelling, although we will never eliminate it completely.
• Swelling is a natural part of your body’s healing process and typically begins hours after surgery ends and continues to increase over the next 48 to 72 hours. As a result, we expect the average patient to be the most swollen on ~ day 3 after surgery. During this period of increasing swelling we have two methods of reducing swelling, ice and NSAIDs (Ibuprofen/Advil). Ice causes constriction of the small vessels in the area which results in a reduction of the fluid that escapes and thereby reducing the accumulation of swelling. Ice should only be applied when a patient is awake because prolonged application of ice can result in burns. We recommend 20 minutes of ice application to the affected area and a 20 minute period to allow the tissue to recover, repeating this cycle while you are awake. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) like ibuprofen/Advil reduce signaling pathways in your body which reduce pain mediators and the accumulation of swelling.
• We expect swelling to peak ~ 72 hours after surgery and then slowly dissipate. Swelling typically takes much longer to dissipate than to accumulate. During this period of swelling resolution we have two methods to reduce swelling, moist heat and elevation. Moist heat promotes dilation of the small vessels in the area and allows the body to recapture accumulated fluid and remove it from the affected area more efficiently. Moist heat should be warm, but not so hot that it causes discomfort. Moist heat can be applied using warmed heating pads available at most pharmacies or with a damp towel heated in the microwave for a short duration. Elevating the surgical area allows gravity to naturally pull swelling from the surgical site. During the day most patients naturally elevate their head, however, sleeping on several pillows such that the head remains elevated at night as well can further expedite the resolution of the swelling.
• Swelling is part of your body’s natural healing process and we cannot eliminate it entirely. Swelling typically peaks ~ 72 hours after surgery and can contribute to postoperative pain and reduced mobility while healing. We can reduce its accumulation and promote is resolution by implementing the strategies outlined above.

ELASTICS (RUBBER BANDS)

Post-operative elastics are crucial to help establish and stabilize your new bite. Depending on your surgical movements, we will show you the location and quantity of elastics that you will be using in the post-operative period. These will change over time, so at each follow-up appointment we will review your elastic use and location as well as provide you with a diagram. You will also be provided with extra elastics and an “attacher” to use should an elastic fall off or break. Please be sure to secure this “attacher” in a safe location. It is normal that the elastics will limit your jaw movement; this is intentional.

PHYSICAL ACTIVITY

Following surgery, you will find that your energy level is much lower. This will take some time to return to normal. when you attempt to return to normal physical activity start slowly and work up to your normal level. Physical exercise such as walking can begin immediately after surgery once you feel able. Other than a light walk, there should be no cardio or weight lifting exercises at this time. Jogging can begin 3 weeks after surgery, light weights 4 weeks after surgery, and heavy lifting or contact sports 6 weeks after surgery. Begin by going shorter distances and at a slower pace than usual to be sure you feel up to the exercise. As your endurance and confidence improve, gradually increase the level of exercise within a level of comfort.

SUTURES

• There will be sutures inside your lip where the incisions were made. These sutures will fall away on their own after 7-14 days. If the sutures fall away early, do not worry, they do not need to be replaced
• If you had lower jaw surgery, there will also be one suture on each cheek. These sutures will also fall away on their own and do not need to be removed.

JAW EXERCISES

Do not attempt to specifically stretch your jaw at this time, passive opening is ok for eating and hygiene. It is normal to have a restricted motion and for your muscles and bones to be stiff and sore. Jaw exercises will be introduced later in your recovery period.

One Week Post-Operative Instructions for Corrective Jaw Surgery

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DIET

You can now begin to progress your diet to a soft, non-chew diet. Remember, the plates and screws used to secure the jaw(s) in their new position take 6 weeks to stabilize, and thus your diet will need to progress slowly. Using a baby spoon can be helpful as it will still be difficult to open your mouth. Examples of food that is safe to consume are:

• Mashed potatoes
• Applesauce
• Oatmeal and pudding
• Very soft scrambled eggs or pancakes
• Any liquids
• Any pureed food

PAIN MANAGEMENT

At this stage most patients are beginning to reduce the amount of pain medication they require as their post-operative discomfort naturally decreases. As your discomfort decreases, you should start be tapering off of the oxycodone, while maintaining the Tylenol and Ibuprofen usage if necessary. Once you are no longer taking oxycodone you can slowly decrease the amount of Tylenol and Ibuprofen, by progressively taking one less pill at each 6-hour dosing interval. It is normal for patients to need some Tylenol and Ibuprofen for up to 3-4 weeks after surgery. As long as you are staying hydrated, continuing to use the Tylenol and Ibuprofen 4 times per day is completely safe. If you still needing the maximum dose of Tylenol and Ibuprofen 4 weeks after surgery, please let your surgeon know.

ORAL HYGIENE

Maintaining proper oral hygiene can be extremely difficult post-operatively, but it is incredibly important to help prevent an infection from developing. We recommend purchasing a baby toothbrush as the smaller size and soft bristles will make it easier to keep your braces and teeth clean. It is important you brush your teeth at least twice a day, taking care to clean the front of your teeth and braces only (do not clean the gums because your surgical incisions are in that area). You may also continue to use the antibacterial mouth rinse (Chlorhexidine) which can help supplement for tooth brushing until you are able to adequately brush your teeth. It is now safe to use a water pik or electric toothbrush if desired.

SWELLING REDUCTION STRATEGY

At this stage the swelling should stop accumulating and start decreasing. Most of the swelling will decrease over the next 2 weeks, but the remainder of the subtle swelling can take up to 6 months. In order to encourage the swelling to dissipate more quickly:

• Apply moist heat to promote drainage of swelling which has accumulated during initial healing phase. (e.g. clay heat packs sold in drug store, moist towel heated in microwave).
• Continuing to elevate your head while sleeping and resting by using several pillows such that your head is above your heart. This will improve swelling draining from the face.

ELASTICS (RUBBER BANDS)

Post-operative elastics are crucial to help establish and stabilize your new bite. It is normal that the elastics will limit your jaw movement; this is intentional. We will evaluate your bite and advise on the quantity of elastics to use and length of time and provide you with an elastic diagram.

PHYSICAL ACTIVITY

Other than a light walk, there should be no cardio or weight lifting exercises at this time. Jogging can begin 3 weeks after surgery, light weights 6 weeks after surgery, and heavy lifting or contact sports 3 months after surgery. Begin by going shorter distances and at a slower pace than usual to be sure you feel up to the exercise. As your endurance and confidence improve, gradually increase the level of exercise within a level of comfort.

JAW EXERCISES

Do not attempt to specifically stretch your jaw at this time, passive opening is ok for eating and hygiene. It is normal to have a restricted motion and for your muscles and bones to be stiff and sore. Jaw exercises will be introduced later in your recovery period.

Three Week Post-Operative Instructions for Corrective Jaw Surgery

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DIET

You can continue to progress your diet but maintain a soft, non-chew diet. You can eat anything you would like that does not require you to place food between your teeth and bite. Remember, the plates and screws used to secure the jaw(s) in their new position take 6 weeks to stabilize, and thus your diet will need to progress slowly. Using a baby spoon can be helpful as it will still be difficult to open your mouth. Examples of food that is safe to consume are:

• Any liquids
• Any pureed food
• Soft, overcooked pasta
• Soft chicken cut or shredded into very small pieces, that can be swallowed without chewing
• Soft flaky fish
• Very soft ground meat cut into small pieces, that can be swallowed without chewing
• Do not eat anything that requires you to mash it by placing food between your teeth, no pressure should be placed on the teeth during eating.

PAIN MANAGEMENT

At this stage most patients are no longer using any oxycodone, but may still be tapering off from the Tylenol and Ibuprofen. Once you are no longer taking oxycodone you can slowly decrease the amount of Tylenol and Ibuprofen, by progressively taking one less pill at each 6-hour dosing interval. It is normal for patients to need some Tylenol and Ibuprofen for up to 3-4 weeks after surgery. As long as you are staying hydrated, continuing to use the Tylenol and Ibuprofen 4 times per day is completely safe. If you still needing the maximum dose of Tylenol and Ibuprofen 4 weeks after surgery, please let your surgeon know.

ORAL HYGIENE

Maintaining proper oral hygiene can be extremely difficult post-operatively, but it is incredibly important to help prevent an infection from developing. We recommend purchasing a baby toothbrush as the smaller size and soft bristles will make it easier to keep your braces and teeth clean. Once you are able to open your mouth and adequately brush your teeth to keep your mouth clean you can stop using the antibacterial mouth since (Chlorhexidine). Continue to refrain from brushing where the incisions were made, just brush the teeth. It is now safe to use a water pik or electric toothbrush if desired.

SWELLING REDUCTION STRATEGY

At this stage ~ 50% of the swelling should have resolved. The remainder of the swelling will continue to dissipate slowly but can take up to 6 months before it is completely gone. Continuing to elevate your head while sleeping and beginning the jaw stretching exercises will continue to encourage the swelling to resolve.

ELASTICS (RUBBER BANDS)

Post-operative elastics are crucial to help establish and stabilize your new bite. It is normal that the elastics will limit your jaw movement; this is intentional. We will evaluate your bite and advise on the quantity of elastics to use and length of time and provide you with an elastic diagram.

PHYSICAL ACTIVITY

It is now safe to begin light cardio activity. Stationary bike, brisk walking, or jogging can begin. However, heavy lifting or contact sports need to wait until at least 6 weeks after surgery. Begin by going shorter distances and at a slower pace than usual to be sure you feel up to the exercise. As your endurance and confidence improve, gradually increase the level of exercise within a level of comfort.

JAW EXERCISES

It is now safe to begin passive jaw exercises. Attempt to gradually increase the amount you can open your mouth by simply using normal jaw muscles. Some mild discomfort might be experienced but keep this within a level that is easily tolerated for a short period of time. About 5 minutes of concentrated jaw movement in the morning, during the middle of the day, and again at night should be sufficient. By the fourth week after surgery you should be able to easily get one finger between your front teeth (10-15mm opening). By the fifth week you should be able to get two fingers between your teeth (20-25mm). If you do not achieve this goal, begin “Hold and Relax” exercises. This involves opening your mouth about one half the amount you comfortably can. Fold your hand into a fist and place your fist under your lower jaw. Using gentle pressure with your hand try to push your mouth closed, use your jaw muscles to resist the pressure from your hand. Hold this pressure for five seconds. Release and spend 30-60 seconds moving your jaw side to side and try to passively stretch and open your mouth without resistance. Then repeat the hold and relax exercise. Do five repetitions of this exercise three times per day.

Six Week Post-Operative Instructions for Corrective Jaw Surgery

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DIET

You can begin to progress your diet back to normal. However, you should be careful and ease yourself back into the foods you enjoy. Tougher foods like apples, carrots, and tougher meats still may be several weeks away. Imagine you have been on crutches for 6 weeks and your doctor just told you that you can walk. If you went for a long run that first day (ate steak), your body just is not ready for that yet. Common sense dictates that food still be somewhat soft and cut into small pieces, as you slowly progress back to your regular diet.

ORAL HYGIENE

You can now resume your normal, pre-operative oral hygiene routine. As always, it is important to continue to keep your mouth and braces clean to avoid dental decay.

ELASTICS (RUBBER BANDS)

Post-operative elastics are crucial to help establish and stabilize your new bite. We will evaluate your bite and advise on the quantity of elastics to use and length of time and provide you with an elastic diagram. At this stage your orthodontist will likely take over the instructions on your elastic use.

PHYSICAL ACTIVITY

It is now safe to progress to more strenuous activity. Let your body be your guide as you progress into more normal activities. It is now safe to begin progression back to sports. As always avoiding being hit in the head and face is recommended.

JAW EXERCISES

It is now safe to begin active jaw exercises. Begin with two or three repetitions of the Hold and Relax exercises you have done previously. Then, place your middle finger on your lower teeth and your thumb on your upper teeth. Apply pressure that creates a feeling that you are stretching muscles with some feeling of tightness or mild discomfort. Hold this for five seconds then release and move your jaw side to side and open and close using just your jaw muscles for 30 seconds. Repeat the finger stretching, placing your fingers on the opposite side. Do three repetitions on each side, and repeat this cycle three times per day. Each time try to slightly increase the finger pressure to produce more opening. (Do this to produce only mild discomfort, do not push enough to create significant pain.) It is normal to be sore after each session, but your soreness should recover by the next morning. If you are waking up with soreness in your jaw muscles you are likely pushing yourself too hard. Reduce your intensity or frequency such that your body can recover overnight. As you can see, recovery from surgery requires a lot of effort on your part. We will be happy to answer any questions regarding diet, hygiene, elastics, exercise, or any other problem which may be of concern to you. Remember, postsurgical progress is sometimes uncomfortable and may occur slowly. However, with some determination and attention to these instructions, you can maximize your healing process. If you have any questions regarding your postoperative recovery, please do not hesitate to call us anytime at (650) 342 – 0213.