After Intraoral Bone Grafts

Bone grafts are frequently harvested from various sites around the jaw bones to assist with long term placement of implants in an ideal anatomical position. The grafts are used to restore normal anatomy following the loss of teeth with an associated loss of bone or alternatively following the traumatic loss of tissues from an injury, infection, etc. The process involves harvesting a block of bone from an area such as the chin, the “angle” of the jaw or a wisdom tooth site and transposing this to another part of the jaw where the graft is usually fixed into position with a small titanium screw. Grafts normally require 4-5 months to heal before an implant can be inserted and generally implants are not inserted until such time as the grafts have completely consolidated. Patients then return to theatre for removal of the fixation screw and implant surgery as appropriate. Where large grafts are required, other distant sites such as the iliac crest may be utilised (see separate instructions).

The information below is a guide for patients to follow on discharge from hospital:

1. HYGIENE/CARE OF WOUNDS.

If food and plaque are allowed to accumulate around the wounds and along the suture lines there is a very real chance the graft will become infected or lost. It is ESSENTIAL to maintain a very high standard of oral hygiene using a combination of Savacol (0.2% Chlorhexidine Gluconate) mouthwash diluted 1 in 10 with warm to hot water and regular toothbrushing. You should commence your mouthwashes and toothbrushing the day AFTER surgery and you should aim to use at least 5-6 mouthwashes per day. Where indicated, a Broxojet may be supplied to assist with oral hygiene. Gentle toothbrushing around the wounds may cause a small amount of bleeding, but it is important to remove food debris and plaque from the area of the wounds.

2. DRESSINGS.

Generally dressings are not used with bone graft surgery however you will be supplied with mouth packs to assist with possible post-operative bleeding. A frequent source of graft material is from the chin and often a compressive dressing will be placed on the chin which should be left for 24-48 hours and then removed carefully.

3. SWELLING AND BRUISING.

Some swelling and bruising should be expected following the harvesting of an intraoral bone graft. Generally swelling takes up to three days to reach its maximum then this will slowly subside over about ten days. Bruising can be unpredictable and may vary from some minor facial bruising to more extensive bruising that may extend to the orbits or down the neck. The bruises slowly discolour with time and may take 10-14 days to disappear. Ice packs should be applied regularly to the face over the first 48 hours. The hospital will normally supply you with several packs to take home; these can be re-frozen and re-used.

4. NUMBNESS.

Local anaesthetic injections are used during your surgery and when you recover you will notice parts of your face are quite numb. This is normal and is done deliberately as a pain control measure. The numbness will take 6-8 hours to wear off and during that time you should avoid contact with hot liquids etc. Bone grafting procedures occasionally cause stretching and injuries to some of the surrounding nerves in the jaw bones and you may notice some prolonged numbness, which can take up to three months to resolve. In severe cases the numbness may take up to 18 months to settle and on occasions there may even be some permanently altered sensation particularly near the graft donor site.

5. BLEEDING.

On occasions bleeding may occur from a grafted site, either the donor or recipient site. You will be provided with mouth packs to take home for use as pressure packs. These should be placed over the wounds and pressure applied by biting firmly on the packs. The hospital will supply you with some spare pressure packs to take home. Rest quietly with your head ELEVATED and if the oozing or bleeding does not stop within 30 minutes please contact the hospital in which you were treated.

6. DIET.

You will need to be on a “clear fluid” and non milk diet (no dairy products) for at least the first 48 hours to allow for some initial healing around the grafted sites. Following that you will need to be on a very soft/blended diet for a week to ten days as the wounds heal and you can gradually increase the texture and variety of foods from that point on. The hospital dietitian can provide you with further information regarding this.

7. SMOKING.

You MUST NOT SMOKE AT ALL following a bone grafting procedure into the mouth. Smoking is well recognised as a major factor in the loss of bone grafts. Patients who are smokers will be advised they must cease smoking at least three months prior to any bone grafting procedure and MUST NOT SMOKE AT ALL following the surgery and the subsequent placement of implants.

8. SPECIAL ASPECTS.

You MUST NOT WEAR YOUR DENTURE OR ANY OTHER PROSTHESIS for at least 2-3 weeks following a bone grafting procedure into the mouth. It may be possible to wear a temporary bridge for an anterior tooth in special circumstances by 2 weeks post-op but Dr. Bowler will discuss this in detail at the time of your surgery. If you wear your dentures too early there is a very real chance of causing wound breakdown and infection and/or loss of the bone graft.

9. POST-OP MEDICATIONS AND SUPPLIES ETC.

You will be provided with the following on discharge:

a) A course of antibiotics.
You will have been given intravenous antibiotics in the operating theatre and sometimes on the ward post-operatively. 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.

b) Analgesics.
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 intraoral bone grafting.

c) Savacol mouthwash.
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 (i.e. 1 in 10) 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.

d) 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.

e) Ice packs.
As indicated earlier 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.

f) Mouth packs.
Spare mouth packs/gauze are usually supplied by the hospital to assist with the control of oozing and bleeding from surgical sites.

10. 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 around a week post-op. Frequently the sutures used for minor oral surgery need to be removed. This is a painless procedure as the sutures stay wet in the mouth and are easy to remove. It is not uncommon for sutures to fall out and this is not a matter for concern. If you do not have an appointment please telephone the practice on 4942 1211 to make a post-operative appointment.

11. EMERGENCIES

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 hospitals and is available most times. If for some reason this is not possible, there is a 24 hour oral and maxillofacial surgery service available through the John Hunter Hospital Casualty Department.