How Should I Manage an AOX Post-Op Wound Dehiscence?

In a recent blog post, I addressed a question I received from a colleague regarding what to do if you cannot get primary closure during your surgery.

I wanted to piggyback on this topic and also address how I manage a post-op dehiscence of my AOX incision.  

In the scenario I will address here, we are assuming primary closure was initially achieved during surgery. However, for some reason, the incision dehisced during the acute post-op period. 

While this is not common, if you cut enough arches, you will see this happen on occasion. 

Typically, the entire incision does not open up. More commonly, one quadrant or one small section of the closure may dehisce. 

This is usually noted at the first surgical follow up, 1-2 weeks post surgery. 

So what do I do if I notice a portion of my incision has dehisced? 

Non-Surgical Management

Chairside Irrigation with Chlorhexidine or Saline

• The first thing I do is one of the simplest, but most effective items on this list. This is nothing more than a gentle Chlorhexidine or saline rinse underneath the prosthetic in the area of the dehiscence.

• Why? Patients often have food or debris stuck under the prosthetic as they are not yet (or should not yet) be using a Waterpik. Many times a piece of food has become lodged in a way that interferes with tissue healing. 

• Removal of the debris allows the process of secondary granulation in this area to begin. 

Prescribe Additional At Home Chlorhexidine Rinses 

• I will continue all of these patients on twice daily CHX rinses until the dehiscence has closed primarily. 

• I will also instruct them to irrigate gently in the area of the dehiscence with CHX or a salt water mixture using a Monoject syringe. This can be done after meals to help prevent food debris from accumulating. 

• Note that I do not prescribe oral antibiotics unless the patient presents with a true infection and evidence of purulence. 

Avoid the Use of a Waterpik 

• I will instruct patients to refrain from any use of their Waterpik in the area of the dehiscence until I give them the green light. 

• I want to visually confirm that the wound dehiscence has healed primarily before any Waterpik use occurs. 

• The force of the Waterpik tends to blow the tissues open and prevent secondary closure, or at the very least, delay it. 

Pain Control 

• Many times OTC pain control is more than adequate. And often no pain control at all is required. 

• However, occasionally I have noted that posterior mandibular dehiscences can be very uncomfortable for patients and I will address these patients individually for tailored pain control measures. 

Close Follow Up

• The patient should be followed until primary closure is confirmed. This schedule depends on the extent of secondary healing required and the timeline in which the patient is able to achieve it. 

• It may look something like this: 

• • Surgery

• • 1 week follow up (*Dehiscence noted)

• • 2 week follow up

• • 4 week follow up

• • Final confirmation of primary closure at 6 week follow up.

In the vast majority of AOX surgical dehiscences, non-surgical management and time is all that is required for these patients to heal. 

However, occasionally surgical intervention is indicated. Here are the few times I will actually step in surgically and what I will do to aid the patient in achieving primary closure. 

Surgical Management

Re-Closure of the Surgical Wound

• It is rare that I will re-close a dehisced wound. This is not required the vast majority of the time, nor is it typically indicated. 

• I will, however, re-close a dehisced wound IF:

All tissue edema has resolved and there is almost no tension on the wound. Meaning both sides of the incision have laxity and have the ability to lay on their own and cover the wound – they simply have had their suture come out early.

In this scenario, I am not pulling the tissue over the wound. I am simply placing sutures to maintain the position the tissue is already in and prevent it from flapping open when the patient is rinsing or eating. 

The patient is in significant pain. I have had this occur on only two occasions. Both instances were in the posterior mandible. In both cases re-closure of the wound (adhering to the above principles) was immediately successful in resolution of the patients pain and sensitivity. The wound was also successful in healing primarily by the next follow up visit. 

The dehiscence is persistent and without noticeable improvement – beyond 6-8 weeks. I have also had 2 separate cases that had small, but persistent dehiscences in the anterior mandible that would not close with non-surgical management of ~ 6-8 weeks. I believe this to be due to the movement of the tongue and subsequent tension on the floor of mouth and tissue in this region. In these cases, time was not enough to allow granulation and surgical intervention was indicated. Re-closure of the flap (along with placement of PRF) was successful in both cases. 

Application of PRF (Platelet Rich Fibrin)

• There are two instances in which I will use PRF in the management of a wound dehiscence. I think PRF is quite magical and effective in many scenarios, including this one. 

Painful dehiscences. 

As noted above, there are times when a patient has significant discomfort and sensitivity due to the bony exposure that occurs with a dehiscence. 

I find this most common in the posterior mandible. 

In these cases I will lay flattened PRF “rectangles” over the top of the alveolar crest and then close primarily over the PRF. 

In cases where primary closure is not achievable, I will still lay the PRF over the crest of the ridge and simply tack it down with stay sutures. This is effective in giving some immediate pain relief to the patient due to the alveolar coverage and also helps speed secondary granulation. 

Refractory or persistent wound dehiscences.

In instances where the dehiscence lasts longer than 6-8 weeks (without significant improvement), or in a case where a closure attempt was made and dehisced again, I will without a doubt use PRF to help aid in healing. 

As indicated above, the PRF is flattened and placed on the alveolar crest. Primary closure or stay sutures are used to hold it in place. This has been very effective for me in difficult dehiscence cases.

P.S. While it is important to know how to manage a post-op wound dehiscence,  this should not be a frequent occurrence. If you feel you are experiencing your incision dehisce on a recurring basis – check back soon for an upcoming article regarding “Why” your incision might be dehiscing in the first place. 

I hope all your sutures are snug, 

And a wound opening is never feared. 

But this is for all the times, 

That darn dehiscence appeared.  

Matthew Krieger DMD