DISCHARGE INFORMATION: TEMPOROMANDIBULAR JOINT SURGERY
Patients who have had temporomandibular joint arthroscopy may go on to require temporomandibular joint surgery, or alternatively patients with conditions too severe for arthroscopy may benefit from open joint surgery. This often involves an arthroplasty, which is effectively a repair of the joint. Sometimes a graft of cartilage will be harvested from the helix of the ear on the same side as your jaw joint surgery to facilitate the reconstruction of the joint. Some patients may require a total joint replacement which involves the removal of a badly damaged joint and reconstruction using an alloplastic (artificial) total joint replacement device or occasionally a costochondral (rib) graft. The information below is a guide for patients to follow on discharge from hospital:
- HYGIENE/CARE OF WOUNDS.
Dressings are usually applied to the wounds in the operating theatre. These can be removed after 48 hours and it is possible to shower providing the wounds are not placed DIRECTLY under the shower head. The wounds can become a little damp but should be carefully dried off with sterile swabs (supplied by the ward) following your shower. Initially your hair should be sponged with a damp towel rather than washed, but after 7 days you can wash your hair properly, but once again the wounds should not get soaking wet.
It is extremely important that patients with external wounds DO NOT TOUCH THEIR WOUNDS WITH THEIR FINGERS. Generally no one has fingers clean enough to touch a surgical wound. You will be supplied with an antiseptic hand wipe while you are on the ward and it is recommended you take this home with you. Ideally the wound should not be touched with your fingers at all for 2 weeks; this includes remembering not to place a telephone receiver or a mobile phone close to or directly onto the wound! Mobile phones are best used on “speaker” during this period. This is particularly important for patients who have undergone the insertion of an alloplastic total joint replacement device. If a device becomes infected from a contaminated wound it could turn out to be a “disaster”.
For patients undergoing total joint replacements, the jaws are frequently immobilised (wired together) using arch bars and intermaxillary fixation (SEE SEPARATE INSTRUCTIONS). The arch bars and wires are left in place following the surgery and these need to be kept as clean as possible with regular toothbrushing and Savacol mouthwashes; a Broxojet may also be supplied by the ward. You should commence your mouthwashes and toothbrushing the day AFTER surgery and you should aim to use at least 4-5 mouthwashes per day.
Generally speaking where there are external wounds, ice packs should not be applied to the face however on occasions these may be used in which case the surgical wounds MUST be covered with sterile dressings BEFORE ice packs are applied. Ice packs should only be applied to the face in TMJ surgery cases where advised to do so by Dr Bowler.
The dressings applied in the operating theatre can be removed after 48 hours. Frequently a small drain will be inserted into the surgical site and this is usually removed 24 hours post-op. For patients who have undergone an auricular cartilage graft to repair the temporomandibular joint there is frequently a dressing sutured into the ear to maintain the shape of the ear and UNDER NO CIRCUMSTANCES SHOULD THIS BE REMOVED as to do so would run the risk of spoiling the shape of the ear long-term. It is always removed by Dr. Bowler at the one week review appointment.
UNDER NO CIRCUMSTANCES should facial ice packs be applied directly to the surgical site for a temporomandibular joint wound – to do so may risk infecting the site as ice packs, despite the best of intentions, cannot be considered entirely clean.
- SWELLING AND BRUISING.
The surgical site following temporomandibular joint surgery will often swell. Generally, swelling takes 2-3 days to reach its maximum and then at least 10 days to slowly settle. On occasions some bruising may be seen in the surgical site and this may take up to 14 days to disappear.
Local anaesthetic injections are used at the time of surgery for pain control post-operatively. Your surgical site will be numb for 6-8 hours following surgery and this will gradually resolve. 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.
- FACIAL PALSY.
The surgical incisions are placed in positions where the facial nerve is usually avoided, however on some occasions branches of the facial nerve may be exposed or stretched and as a result you may be aware of some facial palsy. This frequently presents where the eyebrow on the affected side cannot be fully raised or the eye cannot be fully closed. Sometimes the local anaesthetic injections used at the time of surgery can also cause some temporary facial palsy. Generally the facial palsy is temporary and will slowly improve over several weeks or even several months. On rare occasions there may be a degree of permanent facial palsy evident.
For the first 12-24 hours after surgery WHILST THE DRESSING AND DRAINS ARE IN PLACE, YOU MUST AVOID TALKING, YAWNING, CHEWING, VOMITING, ETC., to keep the movement of the jaw to a minimum. Excessive movement with the drain in place can cause irritation and bleeding of the freshly operated wound.
It is uncommon for a surgical site to bleed post-operatively however if there is some bleeding, rest quietly with your head elevated and apply pressure to the wound. If bleeding persists beyond 30 minutes please contact Dr. Bowler or the hospital in which you were treated. You may notice some dry crusting of blood in the external auditory meatus (ear canal). This is quite normal and should not be “picked at”. It will gradually avulse with time.
It is important to restrict your diet to VERY SOFT FOODS for the first three days. Patients undergoing arthroplasty surgery can build up their diet to a reasonable consistency over 2-3 weeks. Patients undergoing jaw joint replacement surgery with a rib graft need to be aware the replacement joint is screwed to the side of the jaw and full bony union will not be achieved for at least six weeks. In view of this jaw joint replacement patients (rib graft) require a TOTALLY BLENDED DIET FOR SIX WEEKS.
If you are undergoing a total joint replacement using an alloplastic implant, this surgery is frequently done in two stages with the joint being removed and a silicone spacer placed with the jaws wired together for six weeks whilst the prosthesis is manufactured. Under these circumstances, patients require a TOTALLY BLENDED DIET FOR SIX WEEKS. Once the prosthesis is inserted patients are able to resume a relatively normal diet but tend to start with blended foods building themselves up to solids over about 10 days.
Further information on diet can be obtained from the hospital dietitian.
You will be given appropriate advice regarding exercise of your jaw following temporomandibular joint surgery.
f you have undergone an arthroplasty no movements should be undertaken for the first 12-24 hours whilst the drain is in place. Following that the exercises should be relatively gentle and slowly “built up” over about 2-3 weeks.
In the case of jaw joint replacement patients, where a rib graft is inserted, the jaws are wired together for six weeks whilst the rib heals and chewing is NOT AN OPTION. It may be possible to move the jaw if elastic fixation is used but the first solid meal will be at around 6 weeks post-op.
Patients undergoing alloplastic jaw joint replacements are able to chew immediately after the placement of the device. It will however be necessary to use a “Therabite” jaw exerciser regularly over the subsequent 6-8 weeks following your second stage surgery. Dr Bowler will explain the use of a Therabite and will personally supervise your exercises.
It is highly desirable that you do not smoke for at least 12 weeks following the surgery and IF BONE GRAFTING HAS BEEN CARRIED OUT OR IF AN ALLOPLASTIC JOINT HAS BEEN INSERTED, YOU SHOULD NOT SMOKE AT ALL. 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
It is not uncommon for the occlusion or “bite” to feel slightly “out”. This will gradually settle over about ten days and relates to swelling within the joint. For patient who have undergone total joint replacement with a rib graft, it may be necessary for elastics to be used to hold the jaws together for a few days to help the bite settle.
Patients who have had a rib harvested for the purposes of joint replacement will be issued with a “Triflo” device which should be used at least six times per day with the aim of raising all three balls. Patients who are smokers should consider their surgery an opportunity to cease smoking completely!
Harvesting of a rib 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 and your ability to lift objects 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.
Patients may occasionally notice some deafness in the ear on the operated side. This is usually related to some fluid in the ear canal and also some swelling following the surgery as the surgical incision involves dissection down the ear canal. This deafness will gradually subside over 10-14 days and if it persists Dr. Bowler will check your ear with an auroscope and may recommend an assessment from an ear, nose and throat surgeon.
Patients who wear glasses will need to remove the “arm” (“wing” or “temple”) from the glasses on the operated side to avoid contact of the arm with the surgical wound. The arm needs to be left off for at least 14 days to allow the surgical incision to completely heal. Please remember that you normally only ever clean the glass on your glasses and rarely the arms and as a result contact of the arm with the wound could cause an infection.
- 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 T.M.J. surgery.
- Savacol mouthwash.
Where surgery has been performed in your mouth or arch bars have been inserted, 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. A “Broxojet” may also be supplied by the ward.
- 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.
- Oral hygiene/Broxojet.
Frequently patients are provided with a Broxojet irrigating device to assist with cleanliness particularly where arch bars are left on the teeth.
- Chloromycetin ointment (small tube).
You will also receive a tube of antibiotic ointment (Chloromycetin ointment) to apply as a thin smear twice a day to any facial incisions. Please use clean cotton wool buds NOT FINGERS! This must not be confused with the tube of steroid ointment used for the lips.
- 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.
- A course of antibiotics.
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