Monday, 7 January 2013

Q&A Jaw Surgery

Questions & Answers for My Case

Here is a list of questions and answers I have compiled after undertaking orthognathic surgery in the UK in 2011. It is important to note that this is not a professional document or medical viewpoint and the information presented is based on my experience and knowledge as a patient.

  • What exactly are you going to do in the surgery?
I undertook bimaxillary osteotomy surgery to correct my class III asymmetric malocclusion. Designed to straighten, shorten and align my upper and lower jaw with the mid line of my face. My lower chin point was moved 9mm to the left and my upper jaw rotated 2mm right and 2mm forward.

  • Are there any alternatives to the surgery you have proposed?
Although there was a risk of making my TMJ and facial pain significantly worse, I did not have any alternatives available to me.

  • Have you done this type of surgery before?
Mr Shaun Matthews is a top surgeon working for Kings college Hospital in south London. Mr Matthews specialises in oral surgery, temporomandibular joint surgery, maxillofacial trauma and jaw/facial deformity (orthognathic) surgery. He has operated on many cases such as mine.

  • Will I have to have more than one operation?
In my case Mr Matthews hoped to achieve the best results within one surgery.

  • What are the benefits of undertaking this surgery?
To significantly better my bite as my back teeth did not meet at all before the surgery. This surgery was beneficial to improve my appearance and asymmetry.

  • What are the risks of having this surgery?
Anaesthetic has its own risks, which your surgeon will discuss with you.

In my case, post-surgery I experienced numbness of my whole face and tongue. 1 year on, I have most of my sensation back; however I still have no feeling in my chin, lower lip or lower teeth.

Swelling and pain can vary between each individual. I had a high level of pain and was on the maximum amount of pain relief daily, for a period of 8 weeks. Although the pain has decreased over the past year, I am still taking a vast amount of analgesics and using hot and cold packs daily for the swelling.

Another factor surrounding swelling is that the sinus cavities can swell immediately after surgery, which can affect your breathing. However, you will be monitored after your surgery to make sure this does not cause any issues. Directly after surgery and the following few weeks you may experience nose bleeds or blood clots from your nose. Do not be alarmed as this is very normal and ensure you always have a packet of tissues to hand.

As orthognathic surgery puts a large amount of pressure and tort on the jaw joints, there is a risk that you may develop joint pain or may suffer from TMJ dysfunction.

There is also the risk of infection post-surgery. You will be provided with antibiotics intravenously whilst you are in theatre and in hospital. When you are discharged you will be given oral antibiotics to take at home. 

Depending on how fleshy your profile is, this will determine whether the titanium plates can be felt or seen externally. Not in a noticeable way to strangers, but by you the patient. As I have a very thin and bony face, my muscles sometimes pull around my lower plates and the screws and plates on the lower jaw can be seen and felt.

Finally, another risk is that the facial nerve (trigeminal nerve), can become overactive and this can cause pain short term or long term.

  • Will this surgery affect my jaw joints and nerves?
As previously discussed in the risks of the operation, the trauma of this surgery can leave patients with nerve damage and/or joint issues. In my case the trigeminal nerve on the left side of my face runs over the top of my bone (making me a unique case) and this was accidently cut during the operation. The nerve was stitched back together and is partially active again.

  • What is the risk of infection after surgery?
There is a reasonably low risk of infection if you take your antibiotics correctly. However, with any surgery there is a risk of infection. You will be advised on what to look out for and be monitored by your surgeon weekly for the first few weeks.

  • What would happen if I decide not to have the surgery?
I had the possible risk of arthritis in later life and the risk of continued or worsened facial pain.

  • What happens if the surgery is not successful?
You will have to discuss your specific case with your surgeon.

  • Realistically, what should I hope for after surgery, in terms of the way I look and how it affects my jaw function?
Again you will have to discuss your case with your surgeon. In my situation the aim of this operation was to better my facial shape and profile. I had a large curvature on my lower jaw and an inverted upper jaw. Additionally, as I was suffering from chronic facial pain prior to surgery it was hoped by positioning the jaw into a more central position, this may improve or eradicate my pain. Finally, my operation was undertaken to improve my jaw function and bite.

  • Will you be using rubber bands to hold my jaw after surgery or will you be wiring my jaw closed? (Please make your surgeon aware if you have a latex allergy).
I was fitted with 6 plates and 26 screws. I was fitted with 4 titanium plates in my upper jaw and 2 in my lower jaw. I was then fixed with a bite plate for the duration of 24 hours. Elastics were placed onto my brace work to hold my mouth shut (allowing for limited opening). I proceeded to wear these for several weeks after surgery. I am allergic to latex so I had to ensure my bands where pre-ordered by the hospital.

  • Will the plates and screws be permanently left in?
In the UK most people will not have their plates removed as standard procedure. However, in a small number of cases the plates and screws will be removed. I am having my plates and screws removed in December 2012 following unremitting sinus infections and pain in the lower jaw area.

  • If applicable, what will happen if I am allergic to the titanium plates?
Titanium is an inert metal, which means it does not react with anything. However, some people (like myself) have issues such as the muscles pulling on the plate site and this can be uncomfortable.

  • Will you have to remove my wisdom teeth before or during surgery?
I had my visible wisdom tooth extracted a few months before surgery. I have two wisdom teeth that have not yet come out and these were left in by my surgeon as they are positioned very high. In some situations people’s wisdom teeth are removed before or during surgery.

  • Are there any long term issues following surgery? (For example; sinus infections, sensitive and weak teeth, pain caused by the plates or problems with excessive bone growth over the plate sites).
I suffered from pain, swelling, numbness, weak teeth, sensitive teeth and a geographic tongue. I still suffer with reoccurring sinus infections, which are believed to be caused by the screws being in the nasal cavity.

  • How long does the operation take?
My surgery was estimated to take 4.5 hours but took 7 hours in total.

  • Will I have to stay in hospital? If so, how long will I be in hospital for?
The length of time in hospital can vary between 2-5 days. However, if the surgery and recovery go to plan then you will be discharged as soon as possible. I was in hospital for 3 days in total before I was discharged.

  • Will I go into intensive care after the operation or a normal ward?
You do not generally have to go into intensive care, however if your surgery team feel you need this level of care then you may be admitted to ICU. I was admitted to a general ward and was given 1 to 1 care for the time I stayed in hospital.

  • Will I have my own room after surgery?
I was lucky enough to have my own room and en suite. But this does vary from hospital to hospital.

  • Will you be using a bite plate during surgery? And if so will you be leaving the bite plate in place after the surgery?
A bite plate will be used during surgery to help guide the surgeon and stabilise the bite. Moulds and impressions are made during your pre-operative assessments leading up to surgery. In certain cases the bite plate is left in position for a short while after the surgery to enable the jaw to get use to the new position. I woke up from surgery with my bite plate in, however it had to be removed the day after surgery. This was due to the fact it was restricting my breathing and drinking and I constantly needed suctioning off from excess saliva build up.

  • What are my options in terms of pain relief after the surgery?
This depends on the individual.
Immediately after surgery I was taken to the recovery room where I was offered morphine as pain relief. I was on morphine for the first 24 hours. I was then placed on a Paracetamol drip. In many cases you will be given a liquid anti-inflammatory. This is to aid in swelling reduction. However, due to being asthmatic I was not allowed this as a form of pain relief.  When I was discharged I was prescribed co-codamol 30/500mg in soluble form. This can be administered orally via syringe or by small paper/plastic cups. Initially after surgery you should be given ice pacts to reduce swelling and sooth the pain. I continued this at home and used 2 bags of frozen peas in pillow cases placed either side of my face, with the main weight distributed across the top of my head.

  • What happens if I vomit and I am unable to open my mouth?
Vomiting can be a risk but you should be offered anti sickness medication. I was sick during and immediately after surgery in the recovery room. This can be very unpleasant but do not panic as you have one to one care and you will be suctioned off.

  • Will I be able to talk normally?
Talking after surgery can be painful and challenging. But again your capability to talk will depend on your individual circumstance. I was able to communicate by muttering and mumbling and people could understand what I said reasonably well.

  • Will I be able eat and what will I be able to eat?
Again this depends on the individual but you will be on a liquid diet and soft food diet under your surgeon’s direction. In my case, I did not eat anything for the first 3 days and when I did it was just a small amount of soup and watered down fruit juice through a syringe. It took several weeks before I was able to eat soft foods. I purchased some baby spoons and was able to eat small amounts of scrambled egg, mash and custard. To get more information on eating and drink after orthognathic surgery read my helpful leaflet. This can be found on “Steffie’sStuff” Facebook page. 

  • Will there be any external scarring?
After the operation inside your mouth you will have dissolvable stitches across the bottom and top gum line. In rare cases, externally you may have two puncture wounds one each side of your cheek. I had 3 stitches on each side of my face and had visible internal scars along my upper and lower mouth. However, one year on there are no visible signs of the surgery.

  • As some people tend to suffer numbness after this type of procedure… How long before I have complete feeling back?
After surgery you may experience numbness in some part or all of your face and mouth. Generally, the rule is that if you have no feeling after 6 months post operation then it is not likely to come back at all. However, there have been cases where feeling has returned after 18 months post-surgery. Most people only experience a short spell of facial numbness due to the trauma and muscles being pulled around during surgery. Over the course of a few months my face regained feeling; however I still have no feeling in my lower lip and chin. This is one of the biggest risks of orthognathic surgery.

  • How long will it take for the broken jaw to repair fully and be stable?
It takes around 6-8 weeks for the broken jaw to repair.  If you have elastic bands this will help to guide the jaw when moving and get used to its new position. During this period it is advised that you do not lift anything heavy or participate in any sports or heavy exercise

  • How long will it take to fully recover?
Orthognathic surgery can take up to two years to fully recover from, in terms of your physical ability and strength. However, within 3 months post-surgery it would be expected for you to feel significantly better.

  • How will I keep my mouth clean if I am unable to brush my teeth?
On leaving hospital you may be given a mouthwash to rinse with to stop infection. You will be encouraged to start brushing your teeth as soon as you are able. In the beginning, I found using a soft baby brush was beneficial and Corsodyl mouth wash to ease the ulcers and to stop bacteria.

  • On estimate, how much weight should I expect to lose when I am on a soft food diet?
I lost around 11lbs. I lost 7lbs through week one due to the radical change in diet. Your surgeon should inform you on the average weight loss and instruct if you need to add on a few pounds before surgery.

  • How long after surgery will I have to wear my braces?
I wore my braces for 4 months after surgery before they were removed. However, this depends on the individual and how well the teeth meet together after the surgery.

Pictures before and after Jaw Surgery

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