Osteotomies of the Jaws and Major Bone Grafting Procedures
DISCHARGE INFORMATION: OSTEOTOMIES OF THE JAWS AND MAJOR BONE GRAFTING PROCEDURES
Osteotomies are carried out to change the size and shape of the jaws and to correct malocclusions, often in combination with orthodontic treatment. Many of these patients also require major bone grafts harvested from distant sites, such as the anterior iliac crest. Some of these bone grafting procedures are carried out separately to prepare the mouth for implant reconstructions or to repair various defects following trauma.
The information below is a guide for patients to follow on discharge from hospital:
- HYGIENE/CARE OF WOUNDS
External incisions are closed with either non-resorbable or occasionally resorbable sutures and from time to time staples may also be used. The external wounds should be kept as dry as possible for 3-5 days. Frequently an antibiotic ointment (Chloromycetin ointment) is used as a thin smear (not blobs!) applied twice a day to the incision site.
Where an intraoral wound is involved, it is ESSENTIAL to maintain a very high standard of oral hygiene using a combination of Savacol mouthwash diluted 1 in 10 with warm water, regular toothbrushing and, where indicated, a Broxojet may be supplied to assist with oral hygiene. You should commence your mouthwashes and toothbrushing the day AFTER surgery and you should aim to use at least 4-5 mouthwashes per day.
Often you will have orthodontic braces and/or arch bars and ligature wires inside your mouth and these can become a source of accumulated debris. You will be shown how to use a Broxojet to keep your braces and wires clean but it is also possible to use a soft tooth brush and Savacol mouth washes to bathe the wounds.
Frequently a protective dressing may be placed on rib, hip or scalp incisions and these are normally left for 2-3 days. Showering is permissible but the wounds need to be kept out of the water. Bathing or swimming involving immersion of the wound is not advisable. The wounds need to be kept clean and dry and the nursing staff on the ward will show you how to do this.
- SWELLING AND BRUISING.
Some swelling and bruising should be expected. Generally swelling takes up to 3 days to reach its maximum and then this will slowly subside over about 10 days. Bruising can be variable and may involve all of the surgical sites. Generally bruising will slowly discolour and dissipate over about 10-14 days. You will be supplied with ice packs which should be kept on the face continuously for 48 hours. You will be supplied with spare ice packs to take home which can be re-frozen and re-used. Where surgery has been carried out around the orbit, icy wet gauze pads are frequently used continuously for 48 hours and the nursing staff will show you how to do this.
It is quite common for patients to experience facial numbness and occasionally numbness in the donor sites. Local anaesthetic injections are used during surgery to provide for a period of post-operative numbness as a pain control measure. This numbness gradually wears off over 6-8 hours. On occasions sensory nerves in the area of surgery may be stretched or bruised during the surgery and you may experience prolonged numbness that can take several weeks or even several months to wear off. On rare occasions there may be small permanent patches of localised numbness.
From time to time some oozing can be expected from the surgical sites including the donor sites. Normally oozing will settle with pressure. You should rest quietly with your head elevated for at least 30 minutes and apply pressure to the oozing area. If oozing or bleeding does not stop within 30 minutes please contact the hospital in which you were treated.
- NOSE BLOWING.
Patients who have undergone osteotomies of the maxilla (top jaw) SHOULD NOT BLOW THEIR NOSES FOR AT LEAST TWO WEEKS following the surgery. Maxillary surgery involves entry into the maxillary sinuses and nasal cavity and forceful nose blowing could result in air becoming trapped in the tissues (surgical emphysema). This would carry with it an increased risk of infection together with increased post-operative pain. There is also a risk the bone grafts used around maxillary osteotomy sites could be dislodged in some way.
It is quite normal to expect a small amount of nose bleeding for a day or two following maxillary osteotomy surgery. This can be gently “dabbed” with clean gauze and a small amount of “sniffing” is permissible but nose blowing should be avoided.
Patients who have undergone facial/jaw osteotomies and bone grafts into the mouth will need to stay on a COMPLETELY BLENDED DIET FOR AT LEAST 6 WEEKS to allow the facial bones to heal and the grafts to consolidate. In some cases you may be asked to stay on a milk free diet for at least 3 days, particularly where large bone grafts have been inserted into the mouth. Most patients are on a clear fluid diet for the first 48 hours and following that you can commence a fully blended diet. The hospital dietitian will assist with advice in this regard and you can contact her/him as an outpatient.
It is NOT POSSIBLE FOR YOU TO CHEW ANY FORM OF FOOD FOR AT LEAST 6 WEEKS as this will apply pressure to the fixation screws, plates and the bone grafts and will jeopardize your overall result. It is desirable for you to move your jaw and to speak and yawn and Dr. Bowler will encourage you to exercise in this regard as it is very helpful for your overall rehabilitation. Dr. Bowler will discuss this with you post-operatively.
It is highly desirable that you DO NOT SMOKE FOR AT LEAST 2-3 WEEKS FOLLOWING THE SURGERY AND IF BONE GRAFTING HAS BEEN CARRIED OUT YOU SHOULD NOT SMOKE AT ALL until advised by Dr. Bowler. Please be aware that smoking has a systemic effect and a history of smoking can jeopardize the overall success of your surgery. In some cases you may be asked to cease smoking completely for three months before surgery can be considered.
- SPECIAL ASPECTS
From time to time it may be necessary to immobilise your jaws with elastic bands or, on rare occasions, wires to stabilise the end result of surgery. Most commonly patients leave the operating theatre with their mouths open but may be placed into elastic fixation on the day of discharge for 7-10 days; following that time you will be shown how to remove the elastics for feeding, talking, yawning etc. Commonly, elastic fixation of one form or another is used on an intermittent basis during the 6 weeks your facial bones are healing. You will be provided with a small pair of scissors and clips to place and remove the elastics and these need to be returned at the end of your treatment. Patients who are treated with intermaxillary elastics or wires will be provided with a separate sheet of instructions describing the special precautions that need to be taken into consideration if the jaws are immobilised.
The donor site for an osteotomy is frequently the anterior iliac crest. This leaves a 4-6 cm. incision over the crest of the hip. The sutures will dissolve and the dressing applied in theatre should be changed after 48 hours and left in place for another 2-3 days. It is important not to get this dressing wet while showering or bathing and the nursing staff will show you how to avoid this.
It is important to wear loose boxer shorts rather than tight clothing which may press on the wound on your hip. Harvesting of a bone graft will generally prevent you from moving quickly and you will require slow, steady steps to gradually become rehabilitated. Some patients may require a walking frame or stick and you should expect your walking to take 10-14 days to return to normal. It is possible to do some gentle exercise but this should not commence until the drain is removed, approximately 24 hours post-op.
- POST-OPERATIVE MEDICATIONS AND SUPPLIES ETC
You will be provided with the following on discharge:
A course of antibiotics.
You will have been given intravenous antibiotics in the operating theatre and possibly on the ward. A prescription for your oral antibiotics will be available for you to take home or alternatively the ward may have the prescription filled for you before discharge. IT IS ESSENTIAL YOU COMPLETE ALL OF THE ANTIBIOTICS as indicated on the label.
These are also prescribed and the prescription will be available for you to take home or, as with the antibiotics, the ward may have the prescription filled for you before discharge. Generally “middle of the range” analgesics are satisfactory for pain control following minor oral surgery.
A bottle of Savacol mouthwash will be supplied for you to take home. Please use this diluted 1 capful in a glass of warm to hot water and the mouthwash should be used 5-6 times per day, particularly at night before bed. You should start your mouthwashes the day AFTER surgery. You may need to purchase another bottle of mouthwash, depending on the progress of your wounds. Frequently patients are provided with a Broxojet irrigating device to assist with oral hygiene following an osteotomy.
Steroid ointment (Sigmacort – large tube).
A tube of steroid ointment will be provided for you to take home. A thin smear of ointment should be placed on the lips once or twice a day, particularly in the corners of the lips where these may have been stretched, and this can be continued for approximately a week post-operatively. The steroid ointment will assist with healing of the lips.
Chloromycetin ointment (small tube).
You will also receive a tube of antibiotic ointment (Chloromycetin ointment) to apply as a thin smear twice daily to any facial incisions. This must not be confused with the tube of steroid ointment used for the lips.
You will be supplied with ice packs to keep on your face constantly for 24-48 hours post-operatively to help reduce your swelling. The ice packs can be re-frozen and re-used and should make your face feel more comfortable.
- FOLLOW-UP CARE
It is important that all patients are seen for follow-up and generally an appointment will have been made for you to attend Dr. Bowler’s rooms either the day you are discharged or shortly thereafter. Sutures are frequently a combination of resorbable (dissolvable) and non-resorbable (removable) and Dr. Bowler will advise you when these need to be removed. Suture removal intraorally is usually very simple as the sutures stay wet and therefore become easy to remove. If you do not have an appointment please telephone the practice on 4942 1211 to make a post-operative appointment.
If you have any concerns following your surgery please do not hesitate to contact the hospital in which you were treated. Dr. Bowler can be reached through the hospital and is available most times. If for some reason this is not possible, there is a 24 hour service available through Lake Macquarie Private Hospital Emergency Department Tel 02 4947 5700