The postoperative care is also very important as the intraoperative care. With the advent of this direct osteosynthesis technique postoperative care has simpler and safer. The postoperative care is divided into three phases:
1. Immediate postoperative phase—this is the phase when is recovering from the general anesthesia.
2. Intermediate phase—this is a phase before the clinical bony unions has been established.
3. The late postoperative phase—this includes removal of fixation bite-rehabilitation, physiotherapy and long-term observation of dentition.
Immediate Postoperative Phase
This is a phase in which we are highly dependent on intensive care unit staff. In case of absence of such facilities an experienced nurse should remain with the patient till the recovery is complete. An intermaxillary fixation is carried out instruments like cutters, screw drivers and scissor should be easily available near the bed side so that in a case of emergency this fixation can be removed immediately. Patient should be return from the theatre with nasopharyngeal airway in position and this should be left in situ until the patient recovers unconsciousness. In case of patient being unconscious or a patient sedated postoperatively or associated extensive soft tissue injury to the oropharynx. A tongue suture should be taken which should pass transversely across the dorsum of the tongue as an additional safeguard.
A suction machine should be kept beside patient to suck any saliva or oozing blood from the mouth.
In case of vomiting with patients consciousness down there may be chances of aspiration. In such cases immediately the intermaxillary fixation should be removed and accordingly patient need to be intubated.
Intermediate Postoperative Phase
General Supervision
Once a patient gains consciousness tongue suture if taken should be removed.
Patients occlusion need to be checked as early as possible. Any unacceptable reduction need to be corrected in an early stage. Intermaxillary fixation should be inspected for its loosening of wire or removal of wire. A postoperative edema should be kept in a mind and should be informed to the patient and the relatives about it before the operation. Any increase in a swelling with sign of infection require immediate attention.
Prevention of Infection
Cases of fractures of tooth bearing areas injection augmentin + injection mertrogyl should be given for 5 days. If healing goes well antibiotic can be discontinued after 5 days. Simple closed fractures of condyle neck do not require any prophylactic antibiotic.
Oral Hygiene
This play an important role in the prevention of infection in a fracture line.
Hot normal saline mouth washes are given after every meal for conscious patients in a case of immobilization by any of wiring techniques. Patient is asked to do a toothbrush in a visual manner. The size of the tooth brush should be of a smaller size. Betadin gargle or 0.2% chlorhexidine gluconate mouth wash significantly reduce the bacterial count and improves a plaque control in patient with intermaxillary fixation.
Patient who does not cooperate, mouth must be cleaned by a nursing staff after every meal using normal saline solution with the help of hugginson and syringe. Care must be taken not to direct the stream of fluid down the side of nay compounded fractures, so introducing infection. Caps splints can be cleaned with 1–4% sodium bicarbonate solution. Rubber band if soiled with food should be changed. The lip should be kept lubricated with petroleum jelly to prevent drying and sticking of the lips. If the lips are excoriated and sore 1% hydrocotisone ointment can be applied.
Feeding
The problem of providing a patient suffering from maxofacial injury with adequate nutrition varies according to whether the patient is conscious and cooperative or is uncooperative.
Conscious Cooperative Patient
Depending upon a size of the gap between the fixation of the patients can have a semi solid or a liquid diet. A diet of 2000–2500 calories is adequate for most patients nutritional requirement. Liquid or a semi solid diet should be given in consultation with dietitian. Milk and milk products are encouraged for regular daily consumptions. Diet should be supplemented with vitamins iron preparation and high calorie protein preparation such as complain. Use of flavouring agents should be used and liking of patients should be considered to maintain the patients interest in a diet. A big diameter straw can be used for sucking liquids.
Unconscious and Uncooperative Patient
Patients fluid and electrolyte should be maintained. A help of a physician, surgeon, and dietitian is required to maintain the nutrition and metabolism of patients. Rhyles tube should be inserted to feed the patient and if Rhyles tube feeding is not adequate parental fluid therapy should be started with consultation of the physician.
Late Postoperative Care Removal of Fixation
The intermaxillary fixation in terms of wire technique can be removed after the period of immobilization of the specific area fracture. Wire ligatures and eyelets should be unwound a few turn to loosen them and the wire cuts in such a way that there are no residual obstruction in smooth withdrawal of the wire. Nevertheless the process is uncomfortable for the patient. After removal, the mouth should be cleaned with antiseptic solutions, antibiotic is given for 3–5 days as a prophylaxis to the infection with betadin or 1%
chlorhexidine solution for a mouth wash. In a cases of rigid osteosynthesis as it produce stable union not much care is required. Patient should be kept on a soft diet for first two weeks and carefully monitored for any wound infection.
There is no need to remove this fixation unless there is an infection or an exposure in the mouth or extrusion from the skin.
Adjustment of Occlusion
Little adjustment of occlusion is required if wiring technique is employed as the cusps are placed in a correct position under a direct vision at the time of immobilization. In case of caps splint, however, accurate the splint may be
a slight adjustment of occlusion is always required. Slight dearrangement of occlusion can often be overcome by allowing the patient to masticate normally as there is sufficient elasticity in recently healed fracture to allow occlusion to correct itself. Patient with fracture of edentulous mandible can seldom wear their original lower dentures and a new one is required when a fracture is healing.
Mobilization of Temporomandibular Joint
After removal of wires there may be a slight pain in the temporomandibular joint in initial period. Patient need to be encouraged for the movement of temporomandibular joint. Patient is asked to open and close mouth frequently to break the muscles spasm initially, after that there should be no difficulty in moving their temporomandibular joint.
SUMMARY
Patients nutrition should be maintained.
Oral hygiene should be taken special care.
In compound fractures infection should be prevented.
Wire cutters, suction machine should be kept at the bed side.
A dental reference to be done after removal of wires done for the wiring technique.
Implants need not require to be removed unless and until it is exposed, infected or extruded.