Instructions for before and after jaw surgery
We firmly believe the more you understand and are well informed, the better your recovery process after orthognathic surgery will be. Do not hesitate to ask Dr Birbe and his team any doubt you might have.
We strongly recommend you to read and understand all these instructions, which have been written based on past experiences so that they cover all eventual scenarios that can arise.
It´s well documented that a well explained and anticipated surgical process helps patients to better cope with postoperative discomfort.
Moreover, we want to create a good surgeon-patient relationship, to make you feel comfortable, reduce anxiety an ultimately create a trustful relationship.
Much better than surf throughout internet in search of information, we urge you to read, understand and follow these instructions made for your better recovery. So please follow the instructions and advices you will read in this throughout information sheet.
1. Preparing for your orthognathic surgery
We need to know any pre-existing medical condition, illness and medication you are taking. A preop workup will be carried out to rule out contraindications.
A lab test with blood sugar, azotemia, bilirubin, blood coagulation testing, aminotransferases, blood count with thrombocyte analysis, ionogram , urine testing, blood group, HBsAg, HBsAb, HIVAg.
Where applicable, a pregnancy test might be required.
We will also prescribe a Chest Xray and EKG.
Any deviation of standard values of these tests, will be evaluated by your anesthesiologists who might order further studies, and necessitate rescheduling your surgery date. This is especially important when anemia an altered blood coagulation tests are found.
AVOID ASPIRIN, NSAID´S (NON STEROID ANTIINFLAMATORY DRUGS) AND ANY BLOOD THINNER FOR AT LEAST 2 WEEKS PRIOR TO YOUR SURGERY.
Certain foods, supplemental vitamins can act as blood thinners prolonging your coagulation time. Thay also need to be avoided prior surgery. This is the case for PINEAPPLE, ARNICA, GINSENG, ONION, GARLIC AND TOMATOES.
Inform us if you are under any of these medications or dietary supplements.
The healing process is severely affected by nicotine. Smokers need to refrain from smoking at least two weeks before surgery and three weeks after surgery. As nicotine is a strong vasoconstrictor, refraining from smoking will improve your blood circulation in the surgical area, improving and accelerating healing, reducing the risk of infection and bone malunion. It will also avoid the mucosa irritation caused by smoke.
2. Anesthesia
Unless we find a medical problem that needs anesthesia clearing beforehand, you will meet your anesthesiologist on the day of surgery. They will go through the process and ask you several questions like when was the last time you had food or drink, what medications, you take, and if you have any medical condition. He will inform also of potential risks. If you are anxious or scared about injections and needles, it´s a good time to let him know. There are several options to handle this. You are not allowed to eat or drink at least 6h before surgery. If you are on any GMP agonist (semiglutide) since they decrease the speed of bowel movements, it takes longer to empty your stomach and you should be 12h without eating or drinking in this circumstance.
If you need an anxiolytic to sleep the night before, you can take it without problem.
If you are on a specific diet, inform before surgery, since it may be advisable to do some changes in order to avoid prolonged bleeding time issues and healing impairment. Such is the case of vegetarian and low protein diets, that are associated with prolonged bleeding time and altered bone healing.
For female patients, it is important to rule out pregnancy. If you are unsure, you should have a pregnancy test prior surgery. We recommend in addition that you avoid taking contraceptive pills for a month before surgery.
Although swelling is unavoidable, there are several options to minimize it that can be used before surgery:
A run of 2 to 3 lymphatic drainages before surgery will help.
Mouth cleaning and if needed periodontal treatment before surgery will minimize gums swelling.
Remember to brush your teeth and do oral rinses on the day of surgery.
3. Surgery day
Before your surgery, brush your teeth and do oral rinses, without swallowing water. You will be taken from your room to the surgical area with a stretcher. In the preop area, a intravenous line will be placed in your arm and anxiolytic medication will start to be trigger. The intravenous line placement is painless and will be used to administer fluids and medication with no need to pierce your skin every time. It will be maintained until your discharge from the hospital.
In the surgery room, you will be placed in the surgery table and put to sleep. Since the surgery is performed inside your mouth the endotracheal tube will be placed in the nose. You will not notice the placement of the endotraqueal tube, since it is placed once you are slept. Surgery time varies from 40 min to 3h , depending on the procedures. During this time, you will be totally slept.
4.Recovering from your surgery: the post-op period
After surgery you typically will remain in the recovery area for 1 to 2h. When you are fully awake, you respond to verbal orders and anesthesia gives the OK, then you will be brought to your room with a stretcher. Immediately after surgery, a cryotherapy face mask that keeps the skin temperature at 15ºC, will be placed. This will minimize facial edema and you are required to have it in place for 72h. Also, your head will be placed above the level of your heart, so that swelling can drain.
Minor bleeding from the oral cavity and nose are usual. It is not of concern.
You will be able to open your mouth, with some light elastics bands attached to the orthodontic hooks. You will be instructed to remove them to eat and place the back afterwards.
Nasal congestion is expected. It´s a normal and temporary issue that will be dealt with nasal sprays. After a couple of days, you will be able to breath without nasal congestion.
Sometimes, the endotraqueal tube causes some throat ache. It will also disappear in 2 to 3 days.
We suggest you keep your social life, meaning visits during your inpatient stay at the clinic, and during your first postop week at a minimum. Too much social life and activity may lead to fatigue, stress, discomfort and complaints.
We recommend someone calm but energetic and serious assist you during these first days.
In general, as a rule of thumb, you will feel tired after surgery. This feeling may disappear sometimes after 24h, but is usually takes longer, 3 to 5 days. Do not worry about that. This feeling will subside and you will feel much better again shortly.
Depending on the type of surgery, and your recovery after it, you will be admitted for 24 to 48h. To discharge you we look at your drinking capacity, so that we can remove your intravenous fluids, we also will see if you have been able to urinate, have fever and of course if pain is under control.
Rubber bands
In the past ( 20 years ago) after surgery we used to wire your jaws together (intermaxillary fixation) so that your bones heal properly.
Modern surgical techniques use Rigid Fixation (RF) with miniplates and screws. They rigidly fix the bone segments, so that you are able to open your mouth. Since the shape of your mouth and your bite changes, in order to train your brain to the new bite and resting position, we will place elastic bands that will guide you to the new position. They are not intended to keep your jaws together. Furthermore, we encourage early jaws mobilization.
Gradually, over the course of the early postop days, either your surgeon or orthodontist will manage the positioning of these elastic bands, until they are not necessary anymore.
The fact that you are able to open your mouth after surgery, does not mean you can have a normal diet. We require you to be on a liquid diet for a week, soft diet second postop week, and normal diet avoiding hard food from 3r week on. Liquid diet means that you can swallow the food in your mouth without biting your teeth.
For the rubber bands, we will teach you how to place them back after removing them to eat. It is important you place them as you are told. This will give much more freedom of movement at meal times and also for your proper oral hygiene.
Blood loss
So far, we have never had the necessity to do a blood transfusion for orthognathic surgery cases. Blood loss is limited. Nevertheless, if you wish, you can give your own blood for availability up to 3 weeks after surgery. This is not a recommendation nor a requirement. It´s just information in case you wish to do so. If during your preop workup lab test a low hemoglobin level is found (anemia) we will prescribe a course of iron therapy or folic acid, for a month before surgery, depending the cause of anemia.
7. Postoperative nausea and vomiting
In the afternoon after surgery, some patients suffer from nausea and vomiting. Do not worry. I might be a secondary effect of anesthesia drugs, and saline fluid used to irrigate during surgery. Your mouth is open and you can throw out if needed be.
If such is the case., don´t panic. Stay calm, turn your head to the left so that fluid can flow out. Call nursing if you feel nauseous and antiemetic medication will be administered.
If that nauseous feeling persists the following day, please inform us.
8. Nutrition and liquid diet during the first week
You are allowed to resume drinking water 6h after surgery. This will permit to get rid of the intravenous drip, and rapidly recover your strength. Drink water or juices at discretion. The goal is that in a 24h period you drink 2 to 3 liters of water and liquid diet, depending on your weight. It might seem like a lot of drinking, but it is easily achievable taking small sips regularly.
Initially you can use a 50-cc feeding syringe. After a couple of days, you should be able to drink from a glass. Do not use straws, as the negative pressure create can lead to wound dehiscence and liquid into the intraoral wound, and ultimately an infection.
Use a food blender, as this will allow you to eat any food you like in a liquid fashion.
You can prepare non alcoholic shakes, yoghurt, ice cream, fruit juices, soft puddings, and any fluid or mushy food you like. There are protein shakes commercially available that can also be used as a supplement to your diet (Ensure, Meritene, Bio- Manan, etc..)
During the first week, make your meals as liquid as possible.
It is a good idea that before surgery you try different menu options and you get familiar with them and get to know your preferred ones.
After the first week, you can progress to a soft diet, consistency such as scrambled eggs, or boiled potatoes, crepes, pancakes, boiled rice, small noodles, mashed boiled fish or ham, boiled vegetables, etc..
Do not chew hard food until your jaw bones have healed, which is two months after surgery. Until then, you can progress from a soft diet to a normal diet avoiding hard food by postop week 3.
Avoid food such as cutlets, thick bread, pizza or pasta “al dente”, raw vegetables and fruits, such as an apple.
You have to be on a full diet, including meat protein, calcium and vitamins.
The eating problems initially found are the result of intraoral wounds and stiches, weakness of the masticatory muscles (dissected during surgery), throat ache caused by the endotraqueal anesthesia tube, swelling, lip movement changes and numbness of your lips, cheeks and tongue. This is normal and we strongly encourage you to make an effort to resume eating as early as possible after surgery, as this will help a fast recovery.
9. facial swelling after orthognathic surgery
Facial swelling or edema, is an unavoidable secondary effect of surgery. It might vary from one person to another in an unpredictable way and in some patients can be considerable. This swelling typically starts a few hours after surgery and reaches its peak around 72h after surgery. After a week about 80% of swelling it´s gone and by 10 -12 days 90%. There is still a residual amount of swelling that resolves in an asymptotic way. Lower face edema totally disappear in a month, but mid face swelling can persist longer.
A number or actions will minimize the swelling peak and duration.
- Cryotherapy face mask, worn right after surgery ( we will place it in place) and for 72h. This is a very effective measure and we really recommend you stick to it for 3 days.
- Short course of cortisone-based medication for 24h after surgery.
- Maintaining your head elevated (above the heart level) do that gravity helps lymphatic draining of the edema.
- As soon as you are able, resume light activity and walks.
- Avoid stressing situations, long visits of friends, and speaking too long.
- Be rigorous with the prescribed medication. Don´t skip any.
10. Hematomas after jaw surgery
It´s rather unpredictable to know if you will develop hematoma or not. If you do so, they typically appear by postop day 3-5 and gradually dissolves in a couple of weeks. They tend to migrate to the more inferior areas of your neck, toward the chest in a yellowish color. Some heparin-based cream (Menaven) might help a little to dissolve them faster.
11. Secondary bleeding after orthognathic surgery.
Light nose and mouth bleeds can occur after surgery and are rather normal. In order to stop them, we recommend NOT to use straws to drink and NOT to blow your nose heavily for a week. Some vasoconstrictor nasal spray can help for a short course of a couple of days. If bleeding persists, you have to let us know the sooner the better.
Do not take aspirin or any other blood thinner for at least 10 days after surgery. They may cause bleeding. If you have a medical condition that requires blood thinner, you have to let us know that before surgery.
12. Lip movements and ability to speak after jaw surgery .
It´s rather unpredictable to know if you will have difficulties to speak or move your lips after surgery.
The quicker you stimulates lips and speaking ( not for too long, please) the quicker you will fully recover. The vast majority of patients can speak comprehensively after 12h of surgery and normally within few days. We recommend you concentrate on each word, speak slowly, read loud, and do some lip exercises like whistling or pouching.
13. Postoperative pain after orthognathic surgery.
After any surgery, it´s normal to feel some pain. The pain threshold varies a lot form one patient to another. Some patients almost don´t need any pain killers and others more sensitive require more intense pain medication. We have an arsenal of painkillers to treat any pain intensity. Opioid based medication is rarely needed, and is so, no for no more that 24h. Painkillers can be administered orally or injected. The only difference would be the onset of the effect.
The most frequently prescribed oral painkillers are:
-Paracetamol 1g every 6 to 8 h
-Ibuprofen 600mg very 8h
– Enantyum 25 mg every 8h
-Metamizol 1 ampoule drink
– Paracetamol-codeina every 8h
You will not take all of them obviously. Some patients are respond better to one or another.
The most frequently prescribed injected painkillers are:
-Voltaren ampoule in a single dose
-Enantyum ampoule in a single dose
-Orudis ampoule in a single dose
-Metamizol ampoule in a single dose
Throat pain resolves in less than 3 days, especially if you drink . Facial pain is commonly mild, more like tension feeling.
14. Nasal congestion after jaw surgery.
Nasal congestion is due to the insertion of the anesthesia tube and the fact that for upper jaw surgery, we dissect the floor of the nasal mucosa from the maxilla. The nose is congested due to the fact that mucous membrane of the nose, that is the inner lining is swelled. This issue is easily dealt with nasal spray vasoconstrictor such as Utabon or Respir, for a couple of days. Sprays have a better effect when administered lying down, making it possible for the spray to reach the back of your throat. Their effect is very quick and in a couple of minutes you will be able to breath through your nose comfortably.
Nasal congestion will not last longer than 1 to 2 weeks. Vasoconstrictor nasal sprays should not be used more than 3 times a day for 3 to 4 days.
Careful cleaning of your nostrils with a cotton tip humidified with peroxide is also useful.
15. Fever after orthognathic surgery
As a result of your body reaction to any surgery, it´s normal to have a rise on your body temperature up to 38ºC. It´s not a problem. Just a physiologic reaction to surgery. It´s not necessary to take antipyretic medication in such cases. If your body temperature surpasses 38ºC, you have to inform us and in such a case, you will be administered paracetamol.
16. Medication after jaw surgery
There are two phases in the medication you will be prescribed after orthognathic surgery. The one while you are inhouse, and the one you will take at home.
In the hospital, often through your intravenous line, antibiotics, painkillers, anti-inflammatory drugs and lip creams will be prescribed.
At home, you will continue your medication orally, with pills, and they will include antibiotics and painkillers as prescribed.
Antibiotics used for orthognathic surgery:
Amoxicillin suspension or pills, at a dose of 10mg/Kg q 8h for 5 days. That means if you weight 50 Kg , you will need 500 mg.
In cases of penicillin allergy clindamycin 300 mg q 8h for 3 to 5 days.
Analgesics (painkillers) used for orthognathic surgery:
-Paracetamol 1g every 6 to 8 h
-Ibuprofen 600mg very 8h
– Enantyum 25 mg every 8h
-Metamizol 1 ampoule drink
– Paracetamol-codeina every 8h
You will not take all of them obviously. Some patients are respond better to one or another.
The most frequently prescribed injected painkillers are:
-Paracetamol 1g q 6-8h
-Voltaren ampoule in a single dose
-Enantyum ampoule in a single dose
-Orudis ampoule in a single dose
-Metamizol ampoule in a single dose
Throat pain resolves in less than 3 days, especially if you drink. Facial pain is commonly mild, more like tension feeling.
Nasal congestion is due to the insertion of the anesthesia tube and the fact that for upper jaw surgery, we dissect the floor of the nasal mucosa from the maxilla. The nose is congested due to the fact that mucous membrane of the nose, that is the inner lining is swelled. This issue is easily dealt with nasal spray vasoconstrictor such as Utabon or Respir, for a couple of days. Sprays have a better effect when administered lying down, making it possible for the spray to reach the back of your throat. Their effect is very quick and in a couple of minutes you will be able to breath through your nose comfortably.
Anti-inflammatory drugs used in orthognathic surgery:
Some drugs based in natural products such as bromeline, officinalis, ribes nigrum,and arnica are helpful. Once you drink normally you can use a diuretic such as Seguril, 1 tab a day for 3 days.
-Ibuprofen 600mg very 8h
– Enantyum 25 mg every 8h
To stimulate bone formation:
Ideos 1000mg calcium and vit D 880 UI, 1 sachet a day, 30 min before breakfast.
17. Oral hygiene
During your first week, while you are on a liquid diet, we will provide you with a soft surgical tooth brush. You will be instructed on how to use it, In addition, you have to rinse your mouth after each meal with water diluted with some oral rinse with chlorhexidine 0,12% such as Perio- Aid.
You can also dilute some bicarbonate, or peroxide with water for your oral rinses.
After 10 days, you should be able to return to your regular tooth brushing routine. We recommend you continue with your oral rinses, in addition to tooth brushing.
Be careful with water jet oral rinses, since to much pressure, can cause wound dehiscence. That is why we recommend you star using it after two weeks, when wounds are closed, at low pressure.
The surgical sutures used are made of Vycril, which is a self-dissolving suture. Stitches don´t need to be removed unless the bother you.
18. Discharge from the clinic:
Usually, most patients are discharged the morning after surgery. Some international patients that are located in a hotel prefer to stay 2 days at the clinic.
After being discharged, you will come to our office for wound cleaning, postop CT scan, and review of all postop instructions, in case you have any doubt. You will be given an emergency phone number to be used in case needed for the first week. Please do not use after a week, since by then any consult should be dealt through the front desk.
Instructions to follow once at home:
Drink lots of fluids and eat as much as you can
In case of being anxious, breathe deeply 15 times a minute.
Walk around and stand for 10 minutes every hour. It´s not a good idea to stay in bed.
Carefully rinse and brush your mouth and teeth.
In very rare cases, less than 1% a readjustment of the occlusion might be needed. This is generally carried out with local anesthetic and again, is very unlikely you need it.
19. Weight loss after orthognathic surgery
It´s not unusual a postoperative weight loss of 2 to 4 Kg, generally due to loss of appetite, and discomfort. Do not worry. The lack of appetite will disappear, and by the second postop week you will recover your normal weight as you recover your appetite.
20. Sleep and depression after orthognathic surgery.
Remember to keep your head raised above the heart level with 2 or 3 pillows. This will facilitate the draining of your facial edema by your lymphatic system. After a week, you will be able to sleep on your side, taking into account that it is normal you wake up swollen from the side you slept, and this will normalize during the day.
If you have problems to sleep, do not worry. Try to maintain your usual sleep cycle, and you will soon recover it. Take a painkiller before going to sleep. If needed a mild anxiolytic can be helpful. (Loracepam, for example)
Difficulties in swallowing, breathing, swelling, anesthesia, might make you uncertain about the surgery result and make you depressed. Most of the times, this feeling evanishes as you recover your normal functions and return to a healthy diet.
21. Going back to exercising after orthognathic surgery
While we recommend you stand up and walk, avoid intense exercising for at least 3 weeks. During the first week, when you stand up, don´t do it quickly. Allow for some time to your blood pressure accommodate to the position change. It´s a good idea when changing to lying down to stand up, and intermediate step sitting, and then stand up. Walk in a comfortable pace is encourage. Do not go for walks by yourself. Have someone with you in case you get dizzy, for the first week.
Stretching exercises, and light indoor biking could be started by postop day 10-14. Avoid running for a month, and any contact sport for at least 3 months.
You can take a shower the day after surgery, with someone assisting you and in a seated position.
22. Appointments and follow-up with Dr Birbe after orthognathic surgery.
Checkup appointments will be scheduled typically at a week postop, 3 to 4 weeks postop, 3 months, and a completion of the orthodontic treatment. If there is need for any other appointment you just have to call Marta at the front desk. If you are in orthodontic treatment at our clinic, orthodontic appointments after surgery will typically resume at 2 weeks postop. During these appointments you will be able to see both, your surgeon and orthodontist, if needed be.
Postop cone beam scan is taken on the first week, after surgery, typically on your 24h postop appointment. If you travel from abroad for your surgery, after postop week 3 appointment, we can schedule regular follow up videocalls.
Normal jaw motion, and chewing capacity can be accelerated with postop physical therapy. At our clinic we have a fully dedicated physical therapist that will help you and teach you some exercises. This is the quickest and safest way to recover from your surgery.
Dr Birbe will remain in contact with your orthodontist, so that by the second week of your surgery you can resume your orthodontic treatment.
Appointments take place at Clinic B I R B E, tel +34 93 212 47 37
23. Sensory changes and jaw motion and mobility after orthognathic surgery
Orthognathic surgery stretches some of the jaws nerves that are sensory. They do not move muscles, but bring sensation to the gums, lips, cheeks, tongue and palate. That is why temporarily you will have a paresthesia, meaning that the quality of the sensation transmitted by these nerves will not be the same in the short term. In general, a full sensation is recovered between 3 weeks and 3 months, though for some patients it might take longer. Risk factors for pronged recovery are smoking habits, diabetes, immunosuppression, wisdom teeth and genioplasty performed simultaneously, and segmented upper jaw surgery. Facial expression might change in the short run, but will get back to normal in around a month or two.
After orthognathic surgery, and in relation with swelling you will have a limited jaw opening. We recommend you do stretch exercices with your fingers, so that at least an opening of 3cm is achieved by two weeks postop. Full jaw motion should be recovered in a month.
While you are using rubber bands, you might experience some joint tension. If such is the case, we can use lighter rubber bands and recommend physical therapy.
24. Bone grafting in orthognathic surgery
The gaps between osteotomies, will be grafted using your own bone obtained form the surgical area. In cases where additional bone graft is needed, there are several options. It can be harvested from your iliac crest in the pelvis, from your cranium, and in some cases tissue bank or alloplastic bone grafts can be used. We will explain if you are in this need what are your different options. The incisions needed to graft bone are very small, with no esthetic impairment, and no need to shave any hair.
25. Rigid fixation with bone plates and screws in orthognathic surgery.
Rigid fixation of the osteotomies is a requisite to have good bony healing. This is obtained using titanium miniplates and screws. Titanium is a biocompatible material, used in other circumstances such as dental implants, of hip prostheses. It will not beep in airport control and don´t need to be removed unless you wish to do so. Rigid fixation material, also known as osteosynthesis material can be removed after at least three months, when bones have consolidated.
In some cases, usually in relation to one of the screws loosening, a miniplate can cause inflammation and the need to remove it. This procedure can be carried out with local anesthesia as a short chair procedure.
26. Emergencies after orthognathic surgery
You will be given an emergency phone number to be used in case needed for the first week. Please do not use after a week, since by then any consult should be dealt through the front desk. +34 93 2124737 or send a whatsapp message at: +34 626 85 23 63 or an email to clinica@birbe.org
27. Financial issues for your orthognathic surgery
A down payment of 1000 is requested by the time we do your VSP (virtual surgical planning) and the date of surgery is confirmed. This payment is to partially cover surgical planning, surgery booking and dental technicians’ costs.
Upon discharge from the hospital, you will be invoiced for operating theater, anesthetist, medication, room and nursery. It will be in the range of 2500 euros aprox.
Surgeon´s fee are required to be paid before the day of surgery unless otherwise agreed.
If you need financial help, we can do it with our bank.
Our goal is to make the whole process as friendly and optimal for you as we can. Should you have a reimbursement insurance, we will provide the needed documentation for an application to your health provided.
Contact Us
Contact us during our business hours of:
- Monday, Thursday and Friday from 8.00h to 16.00h.
- Tuesday and Wednesday from 8.00h to 18.00h.
- Phone Number: +34 93 212 47 37.
Outside of our business hours you can send us a WhatsApp or a form and we will answer you as soon as possible. Being located in Barcelona, we receive patients from all over the national and international territory.
During your first consultation we will provide you with:
✔ Personal diagnosis by oral and facial examination.
✔ Closed estimate with different financing possibilities.
