Maxillofacial & Oral Surgery Nursing

Zygoma — Tripod Fracture

Fractures at 3 articulation points: zygomaticofrontal suture, zygomaticomaxillary suture, zygomatic arch. Classic mechanism: punch or assault.

• Flattening of cheek (loss of malar eminence)
• Infraorbital nerve numbness (cheek, upper lip, nose)
• Trismus from depressed arch on temporalis
• Subconjunctival haemorrhage
• Step deformity at infraorbital rim

Orbital Blowout Fracture

• Direct blow to globe → increased intraocular pressure → floor fractures
• Diplopia (inferior rectus muscle entrapment)
• Enophthalmos (sunken eye)
• Infraorbital numbness
• Ophthalmology review ESSENTIAL

NOE Fractures (Naso-Orbital-Ethmoid)

• Telecanthus — widening of inter-canthal distance (normal ~30-34mm)
• Loss of nasal projection ("saddling")
• Epiphora (CSF or tear leakage)
• CSF rhinorrhoea — clear fluid, halo test positive, glucose positive
• Periorbital bruising
• Manage: head-of-bed elevation, no nose blowing, neurosurgery input

Why IMF?

Intermaxillary fixation immobilises the mandible against the maxilla to maintain correct dental occlusion while fractures heal or post-operatively after osteotomy. Wires or elastic bands hold teeth in correct "bite" position.

Nursing Care — IMF Patient

Diet with IMF

Patient CANNOT open mouth. All nutrition must be liquid or semi-liquid delivered via syringe or straw through gaps in teeth.

• High-calorie liquid supplements (Ensure, Fortisip)
• Blended/pureed meals passed through syringe
• Ensure adequate caloric intake (often 2000–2500 kcal/day)
• Dietitian referral mandatory
• Monitor weight weekly
• Consider NG tube if intake inadequate

Oral Hygiene with IMF

• Chlorhexidine mouth rinse 0.2% via syringe BD-QID
• Soft toothbrush to accessible surfaces
• Water irrigation using Waterpik/syringe
• Inspect for food debris in wires daily
• Monitor for wire breakage or loosening

Primary Resection

• Wide Local Excision (WLE): Removal of tumour with 1-2cm margin. For T1/T2 tumours of tongue, floor of mouth, buccal mucosa.
• Partial Glossectomy: Partial tongue removal. Speech and swallowing impact. SLT input essential.
• Total Glossectomy: Complete tongue removal. Tracheostomy and PEG almost always required.
• Mandibulectomy: Marginal (preserve continuity) or segmental (defect requires reconstruction).
• Maxillectomy: Palate/maxilla removal — obturator prosthesis or free flap reconstruction.

Neck Dissection Types

• Selective Neck Dissection (SND): Removes specific lymph node levels at risk. Preserves SCM, IJV, CN XI. Used electively for NO neck.
• Modified Radical Neck Dissection (MRND): Removes all 5 levels. Preserves ≥1 of: SCM, IJV, CN XI (spinal accessory). Most common for N+ neck.
• Radical Neck Dissection (RND): Removes all levels plus SCM, IJV, CN XI. Now less common. Shoulder drop from CN XI sacrifice.

Radial Forearm Free Flap (RFFF)

• Thin, pliable skin for intraoral reconstruction
• Tongue, floor of mouth reconstruction
• Donor site: forearm (skin graft required)
• Monitor: forearm donor site and intraoral flap

Fibular Free Flap

• Bone-containing flap for mandible or maxilla
• Fibula provides up to 25cm vascularised bone
• Can incorporate dental implants later
• Donor site: lower leg — peroneal vessels
• Monitor: leg circulation, compartment syndrome

Flap Monitoring Parameters

Tracheostomy Nursing Care

• Suction PRN — maintain clear airway
• Humidified oxygen via trach mask
• Inner cannula cleaning q4-8h
• Stoma site care — clean and dry
• Cuff pressure monitoring 20-25 cmH₂O
• Emergency equipment at bedside (dilators, spare tube)
• Communication: whiteboard, letter boards, Boosey
• SLT-guided decannulation pathway

Nutritional Support

• NG tube: Short-term, placed pre- or intra-operatively. Risk of displacement — check position before feeds.
• PEG/RIG gastrostomy: For prolonged or definitive feeding (total glossectomy, chemoradiation-related dysphagia).
• Dietitian calculates requirements (often 2000-2500 kcal/day, high protein post-surgery)
• SLT swallowing assessment before oral intake
• MUST score weekly
• Monitor weight, albumin, pre-albumin

Chemo/Radiotherapy Effects

• Mucositis — pain management, oral care
• Xerostomia (dry mouth) — saliva substitutes
• Radiation caries — dental review before RT
• Osteoradionecrosis — avoid extractions post-RT
• Trismus — jaw exercises, physiotherapy
• Fatigue, nausea — symptom management

Surgical Procedures

• LeFort I Osteotomy: Repositions upper jaw (maxilla) up, down, forward, or backward. Used for vertical or horizontal maxillary discrepancies.
• Bilateral Sagittal Split Osteotomy (BSSO): Splits lower jaw (mandible) bilaterally to advance or set back. Gold standard for mandibular correction.
• Genioplasty: Chin repositioning — horizontal cut in symphysis to reposition genial segment.
• Bimaxillary osteotomy: Both jaws operated simultaneously — most complex.

Indications

• Class II malocclusion (retrognathia — recessed jaw)
• Class III malocclusion (prognathia — protruding jaw)
• Open bite deformity
• Facial asymmetry
• OSA (mandibular advancement)
• Cleft-related deformities
• Cosmetic jaw enhancement (growing in GCC)

Swelling Management

• Facial oedema peaks at 48-72hrs post-op
• Ice packs / cool compresses first 24-48hrs (15min on/15min off)
• Head of bed elevated 30-45°
• Dexamethasone prescribed pre/peri-op to reduce oedema
• Warn patients swelling worsens before it improves
• Significant bruising and ecchymosis is normal

Occlusal Splint Care

• Acrylic splint wired in place between teeth to maintain occlusion
• Check splint is intact and secure — report loosening
• Clean around splint with irrigating syringe
• Splint typically removed 4-6 weeks post-op

Rubber Band Traction (Elastics)

• Guide elastics applied to dental arch bars post-op
• Change elastics as prescribed (usually daily or BD)
• Teach patient (or family) how to change elastics before discharge
• Elastics are thinner than IMF wires — patient can open slightly if vomiting — but wire cutters still required

Fluid and Nutrition

• Oral intake restricted to liquids for 4-6 weeks
• High-calorie supplement drinks (Fortisip, Ensure)
• Syringe feeding technique — patient sits upright
• Dietitian input mandatory
• Nasogastric tube if intake consistently inadequate
• Progress to soft diet at 6 weeks per surgeon instruction

Post-Operative Care

• Elbow splints (No-No's): Prevent child putting hands/fingers to mouth and disrupting repair. Applied to both arms. Ensure neurovascular checks q2h — colour, sensation, warmth of hands.
• Suture line care — clean gently, apply ointment as prescribed
• Oral hygiene: rinse with saline after feeds
• Analgesics prescribed regularly — paediatric dosing
• Oxygen saturation monitoring — airway oedema risk
• Positioning: lateral or semi-prone to protect airway

Feeding Techniques

• Pre-repair: specialist cleft bottles (Haberman, Pigeon feeder) — softened teat, minimal sucking effort required
• Post cleft lip repair: may resume breast or bottle feed with guidance
• Post cleft palate repair: cup, spoon, or syringe feeding for 2-4 weeks; no hard teats
• NG tube if feeding difficulty — short-term
• Upright position for all feeds — reduces regurgitation through nose

Family-Centred Care

• Emotional support for parents — grief, shock, guilt are normal
• Connect families with cleft charities and support groups
• Realistic expectation-setting about staged surgery
• Involve parents in all care decisions and teaching
• Cultural sensitivity: family members as primary carers in GCC context

Key Post-Op Priorities

• Facial nerve monitoring — primary concern
• Drain management — suction drain in wound
• Pressure dressing — reduces haematoma and salivary fistula risk
• Monitor for haematoma — expanding neck swelling = emergency
• Oral intake: soft diet initially
• Wound inspection: Frey syndrome awareness

House-Brackmann Facial Nerve Scale

Assess and document facial nerve function every nursing shift post-parotidectomy.

Grade I: Normal function. Grade VI: No movement at all. Document which branches affected (temporal, zygomatic, buccal, marginal mandibular, cervical).

Drain Management

• Vacuum suction drain — keep compressed (active suction)
• Record drain output hourly for first 4hrs, then 4-8hrly
• Expected output: reduces significantly after 24hrs
• Concern: sudden large output (haemorrhage) or milky fluid (chyle leak)
• Remove drain typically at 24-48hrs when output <20-30ml/24hrs

Frey Syndrome Counselling

Chyle Leak (Rare)

• Milky/creamy drain fluid — injury to thoracic duct or lymphatic vessel
• Confirm with triglyceride levels in drain fluid
• Low-fat diet or medium-chain triglyceride diet
• May require surgical ligation

Sialolithiasis (Salivary Stones)

• 80% submandibular gland, 20% parotid
• Pain and swelling at mealtimes (salivary colic)
• Management: hydration, massage, sucking sour sweets, sialadenoscopy (endoscopic stone removal), submandibular gland excision if recurrent
• Nursing: encourage oral fluid intake 2-3L/day, warm compresses, analgesics

Sialadenitis (Gland Infection)

• Painful, tender, swollen gland — unilateral usually
• Pus expressible from duct opening in parotitis
• IV antibiotics if severe (Staphylococcus most common)
• Nursing: oral hygiene, hydration, warm compresses, regular mouth rinses
• Monitor for abscess formation — requires drainage

Sjögren's Syndrome Oral Care

• Saliva substitutes (Biotene, Oralbalance gel) QID or PRN
• Stimulate residual saliva: sugar-free gum, malic acid spray
• Fluoride toothpaste and daily fluoride gel
• Antifungal prophylaxis (nystatin/miconazole)
• Frequent small sips of water throughout day
• Avoid caffeine, alcohol, antihistamines — worsen dryness
• Pilocarpine — systemic secretagogue (if no contraindications)

TMJ Management Spectrum

• Conservative: Soft diet, jaw rest, NSAIDs, physiotherapy, splint (occlusal guard)
• Botox for Bruxism: Masseter and temporalis injections reduce parafunctional clenching. Effective 3-6 months. Nurse monitors injection site comfort, assesses for spread to adjacent muscles (rare).
• Arthrocentesis: Bedside procedure — lavage of TMJ via two needles. Post-op: soft diet, jaw exercises
• Arthroscopy: Endoscopic joint lavage and lysis of adhesions. Day case. Ice packs, jaw exercises post-op
• Total Joint Replacement: Alloplastic (metal) prosthesis. Reserved for end-stage disease.

Post-TMJ Surgery — Nursing

• Pain management: regular analgesia for first 48-72hrs
• Diet: soft diet 4-6 weeks (no hard, chewy foods)
• Ice packs first 24-48hrs to reduce swelling
• Jaw exercises: prescribed opening/lateral exercises from Day 1 to prevent scar contracture
• Physiotherapy referral at 2 weeks
• Wound care: small preauricular incision
• Monitor: drainage from wound, facial nerve function

Jaw Exercise Guidance (Patient Teaching)

• Maximum active opening: 5 reps x3 daily
• Lateral jaw movement: 5 reps each side x3 daily
• Protrusion exercises: 5 reps x3 daily
• Stacked tongue blades — passive stretching as directed
• Physiotherapy referral for guided exercises

Shisha (hookah, water pipe, narghile) smoking is deeply culturally embedded across the Arab world and South Asia. Cafes and homes regularly feature shisha. It is often perceived as safer than cigarettes — a dangerous misconception.

Clinical Risks

• One session produces 100-200x the smoke volume of a cigarette
• Carbon monoxide, heavy metals, volatile organic compounds
• Directly linked to oral SCC, pharyngeal cancer, laryngeal cancer
• Significant periodontal disease association
• Shared mouthpieces — risk of herpes, tuberculosis transmission
• Nicotine addiction — comparable to cigarettes

Nursing Role in Shisha Counselling

• Brief intervention: ask, advise, assist, arrange
• Refer to smoking cessation services (NRT, varenicline)
• Document shisha use in nursing assessment
• Oral cancer screening: inspect mucosa, tongue, floor of mouth
• Refer suspicious lesions urgently to OMFS

Khat (Qat)

Leaves of Catha edulis chewed for stimulant effect (cathinone). Legal in Yemen but illegal in most GCC states. Still consumed in large Yemeni and East African diaspora communities in Saudi Arabia and UAE.

• Held against buccal mucosa for hours — chronic mucosal exposure
• Associated with oral submucous fibrosis (OSF) — precancerous
• Periodontal disease, staining, halitosis
• Psychoactive — dependency, mental health concerns

Smokeless Tobacco (Pan/Naswar/Gutka)

Widely used by South Asian workers in GCC (largest expat group). Pan = betel leaf + areca nut + tobacco. Naswar = fermented tobacco paste. Held in buccal sulcus.

• Oral Submucous Fibrosis (OSF): Precancerous condition — fibrosis of buccal mucosa causing trismus and difficulty swallowing. Malignant transformation rate ~7%.
• Oral SCC risk 5-10x above baseline
• Nurse role: mucosal inspection, cessation counselling, OSF monitoring, biopsy referral for suspicious lesions

Nursing Implications

• Patients may arrive with inadequate follow-up plans
• Language barriers with diverse international patients
• Compressed timelines — discharge pressure conflicts with clinical safety
• Pre-existing conditions not disclosed or documented in English
• Continuity of care post-return to home country
• Clear discharge instructions in patient's language

Cosmetic Facial Surgery in GCC

• Rhinoplasty is the most performed cosmetic facial procedure in GCC
• Genioplasty (chin reshaping) growing rapidly
• Bimaxillary protrusion correction sought by Arab/South Asian patients
• Nurse role: post-op swelling education, wound care, psychological support, realistic expectation management
• Particularly important: body dysmorphic disorder (BDD) screening — nurses can identify patients with unrealistic expectations

Fasting and Oral Hygiene

During Ramadan, fasting Muslims avoid eating, drinking, and sometimes swallowing anything from Fajr to Maghrib. This creates specific oral health challenges.

• Many patients avoid toothbrushing — fear of accidentally swallowing toothpaste or water breaks fast
• Reduced salivary flow during long fast hours — caries and periodontal disease risk
• Dehydration → xerostomia → mucosal vulnerability
• Miswak (traditional tooth stick) is widely accepted during fasting — encourage use

Nursing Guidance for Ramadan Patients

• Encourage oral hygiene between Iftar and Suhoor
• Fluoride toothpaste and regular rinsing at non-fasting hours
• Chlorhexidine rinse: acceptable during fast (spit, don't swallow)
• Address medication timing — work with medical team for Ramadan scheduling
• IMF patients: especially important to maintain oral hygiene at Iftar/Suhoor times

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