Gum graft diary: Day 5 & stitches

Sutures, sutures

The swelling is still hanging around but is not any worse. Still painful and sore in places where the stitches have been pulling particularly hard.  Graft is mostly pale pink and white; however, one tooth is particularly painful and the grafted area there is red.  

Even though the AlloDerm graft should ideally be completely covered by your own gum tissue, all the movement caused by the swelling can mean that parts of it get exposed.  You will notice this as white bits that stick out behind the pink gum tissue.  

This is OK - a little bit of exposure (maybe 1mm or so - you may even get away with more). Those exposed white bits can eventually be incorporated into your own gum tissue just like the rest, and you will see them gradually get pink as they become vascularised. Be gentle with them to increase their chances of survival, otherwise they can get knocked off - in which case they definitely won't be incorporated into the gums.  For AlloDerm patients, compliance with post-surgical care (soft diet!) is more important than for those with connective tissue grafts (grafts that used their own mouth tissue).

Today's theme: Stitches

Your stitches will go through a lot in the first few days while they cope with the swelling. The graft will pull against them and look puckered, with horribly uneven edges because the tissue is only held down in the places where the sutures have been placed.  As the swelling goes down, things may look uneven because the stitches aren't straining to hold such big puffy gums any more, and bits of the graft may become exposed. A few of the stitches may become loose as well.  

You will have two layers of stitches:

• Graft sutures: The lower layer of stitches holds the grafting material in place inside the pouch created for it underneath your gums. They will probably also put some glue-like material in there (Emdogain) that helps to stimulate tissue regeneration.
• Surface sutures: The second layer of stitches holds your gums over the graft. For alloderm, this is particularly important as the donor material should not be exposed to air.  

I was impressed with the method my surgeon used. She glued all of my teeth together at the top to create anchors that she could sling the stitches around. The glue is just a little dot of white/clear liquid between each tooth, a bit like composite filling material.  I think it looks really neat, and the stitches are straight and line up with the gaps between my teeth. 

I don't remember my surgeon back in 2012 doing this.  Maybe he did and I didn't notice, but the stitches certainly look nicer this time around. 

My loose stitch!

However, one of the bonds between my teeth popped off so the stitch is hanging loose. My periodontist asked me to send a photo - on this basis she said it was probably fine and I should just leave it.


She left the ends of the stitches quite long as well - apparently to give a bit more room for flexing if needed.  My previous surgeon back in 2012 cut the stitches short, so that seems to be a personal preference.  

Things to stock up on

How to make recovery suck less

You're about to go through a major surgery, so it's good to prepare first and make sure you have everything you need for a speedy, comfy recovery.  

These are all things that I personally found helpful - although you might not need everything here.  

Mouth rinses and gels for sore gums

I found that these products helped to speed up the healing process and maximise the chances that the graft takes:

• Curasept. If you are given Corsodyl, buy this instead!  It has the same active ingredient but it won't stain your teeth.
• Gengigel Gel. This really helped to soothe my mouth when it was feeling hot, tight, dry or sore. The gel is easy to use and thick enough that it seems to last in the mouth for a good while. Gengigel has been shown to help speed up healing and reduce inflammation, and I found it really works. 
• Gengigel Mouthrinse. This was also useful to make sure I could get the product into all nooks and crannies. This stuff helps to heal gums! 

Things to help with swelling

Excessive swelling is a big reason that grafts fail - this is because it can pull the stitches loose and expose the immature graft underneath.  Icing in the early stages can help - once the swelling sets in there isn't much you can do except wait for it to go down.  The key is in prevention during the first 24 hours (after this, ice feels nice but doesn't reduce the swelling much).

• Ice packs - any kind of reusable gel ones are great. I have Theraflex ones, which have held up for years and years. They remain soft enough when frozen to mould nicely to your face.
• Swanson Enteric Bromelain. Enteric bromelain can help to reduce swelling after surgery or injury. Check with your doctor before adding supplements.

Things to help with bruising

You might not have a big problem with bruising, but if you do, these things can help:

• Nelsons Arnicare Arnica Cream.  Brings down bruising like magic. 
• Vitamin K. Used by plastic surgeons to reduce post-surgical trauma, but please check with your periodontist first. 

Gum graft diary: Day 2 - first day after surgery & post-op instructions

Good morning - first day after AlloDerm gum graft on all teeth

I woke up without much pain today, after having all of my teeth grafted (more on the surgery itself here).  No one is more surprised than me. 

It is definitely best to take the day after surgery off work - in fact, I have the rest of the week off.  I noticed that swelling increased throughout the day and I was quite puffy in the evening.  I am trying not to speak or move my mouth too much - when I do, it feels like it contributes to the swelling.

I have not tried to look at the graft, but since it has been done right at the front I can see parts of it anyway - it is quite red but held in place with the stitches.  Today.  I know from experience (the last bout of grafts in 2012...), that it will probably look horrendous if I have a closer peek.  

Today's theme: Post-op instructions

Let me read out my post op instructions for you below.  I'm the kind of person that needs to be told why I should follow them, otherwise I may just forget to comply:

• Plenty of rest - seems obvious. Try to sleep with extra pillows to keep your head elevated and reduce swelling.
• Do not bush or rinse on the day of the surgery. After the first day you can very gently rinse by tilting your head to let the mouthwash move around your mouth (no swishing!).  Not brushing for so long feels kind of icky, but my surgeon will give my teeth a good clean and polish when I come in for review appointments to make this part easier and more socially acceptable. 
• Avoid lifting the lip with your fingers to look at the area.  As I note here, it's best not to look. You can accidentally tear the sutures, and because the tissue is so delicate, they might not be able to replace them. You may think you are being gentle, but your gums may disagree.
• Apply ice, 15 minutes on and 15 minutes off.  There is some debate over this one, but as I understand it the ice helps to bring down swelling.  A little bit of swelling is good as it brings nutrients to the area; a lot is bad since it can break the stitches.
• Start taking painkillers before you feel the anaesthetic wear off. It is much easier to prevent the pain than it is to make it go away once you start feeling it.
• Take the medication with food and drink. This reduces stomach upsets.
• Eat a soft diet. More on this in Day 4.  The first 24-48 hours are the most critical for your graft, so be extra careful for the first few days. 
• Avoid exercise for 7 days. This keeps blood pressure low, reduces bleeding and aids healing. As an avid gym bunny, this one is extremely difficult for me. More on this in Day 7.

Too much swelling is a bad thing and can lead to graft failure.  Icing in the early stages can help - once the swelling sets in you just have to let it take its course, so the key is in prevention. 

I use Theraflex gel packs, which have lasted me for years and years.  Wrap these in a tea towel before pressing against your face to prevent freezer burn!  They remain soft and flexible so they can fit nicely against your cheek. 


Have you had gum grafts - were your post-op instructions different ?  Leave your comments and tips below, let's all help each other! 

Gum graft diary: Day 1 - the surgery

Before the surgery

I was quite nervous in the morning, but I did a huge workout (no exercise for 7 days after the surgery) and ate a massive lunch consisting of all the crunchy, crispy, chewy delicious things that would be forbidden for the next few weeks. 

At the clinic

I opted for oral sedation, which is essentially a sleeping pill that I took half an hour before surgery, along with the first dose of antibiotics. The oral sedation leaves you mostly conscious through the surgery itself so that you can still respond to instructions, but makes the time go by faster. Since my surgery was around 4.5 hours long, the surgeon recommended this to me.

PS - last time, in 2012, I went without oral sedation. The surgery was about 2 hours, and it was totally fine. 

Personally, I didn't find too much of a difference - although it was definitely relaxing, I didn't think it was essential.  But I am not a nervous patient. If you are really nervous, definitely go for the sedation.

In the chair

Many people will tell you that the worst part is the injections, and I agree.  For the rest, you can just feel sensations of pressure, maybe some tugging, but that's about it. There really is nothing to be afraid of. 

During a very long surgery like mine, the anaesthetic might wear off. Don't worry, it doesn't just suddenly disappear from your system and leave you in agony - you will just notice a sharper tugging feeling and maybe a little pain (like during the injections). Just stick up your hand and ask for more numbing.  

Halfway through the surgery, we stopped and I took oral painkillers (ibuprofen), since the anaesthetic would have worn off on my top arch while the surgeon was still working on the bottom arch.  

My surgery was done using the "tunnel" technique, which means all that tugging had involved:

• Root planing - to clean your teeth and prepare the surfaces so that the graft will be able to attach to them
• Incisions - cutting into the gum to create a pocket for the alloderm, leaving the papilla (the bit of gum between your teeth) intact
• Dissection - using an instrument to lift the gum away and to join up all the pockets from the bone
• Hydrate the alloderm material and insert it into the first pouch - the alloderm itself looks unremarkable, a sort of white/pink rectangle of soft material.
• Pull the AlloDerm through all of the pouches - so it lies across all the teeth that are being grafted. 
• Suture the AlloDerm in place, then suture the gums over the AlloDerm - this part may take the longest, as there are about 4 loops per stitch. 

The tunnel technique is best because it leaves the papilla intact, and that means better blood supply to the graft area.  Blood supply is absolutely key in making sure that the graft takes! 

Afterwards

My husband picked me up from the surgery and we got a taxi home.  I held a small icebag on my face on the way back and went straight to bed. I didn't have any noticeable pain or bleeding overnight.  Fingers crossed for a good outcome this time!

If my surgery sounds like it was a breeze, that's because it was!  I think a lot of it has to do with choosing a very experienced surgeon, as I've read a lot of horror stories - but if you are reading them and getting scared, please be assured that there are lots of good experiences too!  

Has anyone else got a story they want to share? Good or bad, leave a comment below and you will probably help someone out! 

Gum graft diary: Before the big day - all about supplements

What supplements to take prior to getting a gum graft?

OK, you have a date booked in, but what supplements can you take pre- and post-op so that your recovery doesn’t totally suck?

The first time I had a gum graft in 2012, I did no preparation and it was miserable.  I prepared obsessively for my second time in 2017 – probably overkill – but I was determined to minimise discomfort.    

I’m not a general believer in vitamins and supplements for day-to-day life, but you’re about to put your body through some surgery/trauma and there are things that it needs to recover.

There are a boatload of recommendations for various vitamins and minerals to be taken prior to any kind of surgery. There is research to back up most of these, due to their role in accelerating wound healing and immune function.  A few useful links are here and here for you to read at your leisure, or you can skip to the summary below. 

I spent days reading up on the research and there does seem to be good evidence that these things help – but A LOT of things apparently help!  I've listed the supplements I personally took below… most are fairly cheap solutions and they have research to support them.  You don’t have to take any of these if you don’t want to, I’m just sharing what I felt was helpful for me.

Multivitamin and mineral formula

• What’s it for?  Instead of buying everything that is supposed to help individually, I just got a multivitamin that looked like it covered all of the bases and was reasonably affordable.  
• What type? Anything that includes high doses of  B vitamins, vitamin K, Biotin, Zinc, Selenium, Chromium.
• What dosage? As directed
• Price? My choice was Wellwoman, which was the cheapest high quality multivitamin/mineral formula I could find that covered all bases.  The Wellman formula is pretty similar, but I went for Wellwoman because of its higher dosage of B vitamins and other lovely things more targeted to supporting healthy skin.
• Wellwoman original: see it here (UK) or here (US)

Vitamin C

Your multivitamin of choice may or may not already have a ton of vitamin C, but we’re talking about way more than the recommended daily intake here so you may want to boost it. 

• What’s it for?  Helps immune response, protects against free radical damage and also aids the production of collagen and components of connective tissue. It’s considered so essential to these functions that A&E patients are given infusions of vitamin C.  
• What type? L-absorbic acid is the gold standard.
• What dosage? Take high dosages for 2 weeks prior to surgery to ensure that your blood concentration is high.  Continue with 1-2g per day during the healing period
• Price? Cheap as chips. I either get it in powder form from Amazon for a few quid. But it is also found in most cold and flu vitamins, where you can get the added bonus of zinc (which also helps healing). I quite like Sambucol because it tastes delicious.
• Vitamin C powder: see it here (UK) or here (US)
• Sambucol Black Elderberry tablets: see it here (UK) or here (US)

Co-enzyme Q10 / Ubiquinol

There are several studies purporting a link between Co Q10 and gum health. Personally, I don't feel the need to take it all the time, only for the surgery. 

• What’s it for? Improved mitochondrial energy activity and reduces recovery time. Especially helpful for gum tissue.
• What type?  Ubiquinol is the reduced form of CO Q10 that is better absorbed in the body
• What dosage? 150mg daily, before and after surgery.
• Price? These are usually pretty expensive - I got mine from Amazon - here are some suggestions:
• Solgar Ubiquinol - see it here (UK) or here (US)
• Swanson Ubiquinol - see it here (UK) or here (US)

Bromelain

A lot of the discomfort after your gum graft will be due to the swelling.  Since I am a champion sweller, this was one of interest to me. Skip if this does not apply to you, and please consult your surgeon because it may interfere with certain medications.

• What’s it for? Used to reduce swelling after surgery or injury 
• What type? Studies seem to be mainly on the enteric coated type (the kind that only dissolves once it reaches your intestines
• What dosage? Start 3 days before surgery and continue for 7 days after. 500-2,500mg per day
• Price? I got mine on Amazon, as it was the only place that I could find the enteric type
• Swanson Enteric Bromelain - see it here (UK) or here (US) 

Do you have anything to add?  As ever, everyone is different, and we can help each other by sharing our experiences! 

Healing after a gum graft - what does it look and feel like?

Don't look!!

That is the advice that we all get, and maybe lots of you have the self-control to avoid it.  

I didn't!  But you should, you absolutely should have the self control, because it will help the area to heal faster and minimise any risks of complications.  This is so important.  So let me be a dummy for you, and keep your mitts off that gum graft!

Seriously, try not to look at it - enjoy reading about it below instead.  You can also read much more detailed information in the daily diary from my procedure in 2017, where I also include tips and tricks to help improve your chances of a successful graft. You might also want to look at possible supplements to speed your healing.

OK, but what would it look and feel like?

I found it very frustrating before my surgery that there was so little information on what the site should look like during the healing process - only nice, clean before and after photos. It can be very distressing not to know if what you are experiencing is normal.  

So, you can read my experience from back in 2012 below - this is for alloderm grafts, I can't comment on other types but I have read that it is fairly similar.  

Day 1

You will probably have lots of swelling, maybe some small amounts of bleeding, but the stitches are holding everything in place. For me, everything looked very pink/red and sore at this stage.  Wahay!  

You might be able to taste blood sometimes - I had this a little bit - but your surgeon should have given you some gauze to help with any oozing and other loveliness.  

You might also feel quite sick, if you managed to swallow blood or don't react well to the anesthetic.  The surgeon's assistant should be on hand with the suction but sometimes they don't get everything.  I felt quite sick after my first surgery in 2012 and even threw up later that night (not good - apparently this is unusual though). 

Day 2-4

Swelling might be increasing in the following days (it typically peaks at day 3-5), and maybe on one side more than the other.  You might also be getting a bit of bruising starting to develop on your face.  I had a bit on my right cheek, but I used Nelsons Arnicare Arnica Cream to help this. It really takes bruising down quickly!

The graft will probably have swelled up too, so it looks like it covers more of your tooth than you wanted. I was scared about this, but don't worry, it will go back down.  Any pain can be controlled with ibuprofen.

Things will look really ugly, especially where the tissue is pulling against the stitches. The graft will be a mix of pink and white tissue.

Day 5-7

Swelling should be past its peak by now and be starting to come back down. Sometimes I had a sort of "throbbing" sensation, that wasn't quite pain, but apparently that is OK.  If you still have a lot of pain and increasing swelling, go to your surgeon as it might be a sign of infection.

When I ate or used my mouth, I could feel a pulling or almost "ripping" sensation that freaked me out.  That was the stitches pulling on my gums.  Don't worry about it, but try to be gentle and keep on with that soft diet. I also found that using Gengigel Gel really helped to soothe the area. The gel is quite convenient and seems to last in the mouth for longer, but I also used the Gengigel Mouthrinse to make sure I could get all areas. This stuff helps to heal gums! 

It's really important to avoid tearing the sutures because the tissue is too delicate for the surgeon to replace them right after the surgery, and ideally those stitches should help hold everything snug against the teeth. The human body is amazing and will probably manage to heal if you do mess a few up, but best to give it all the help it can get. 

My gums had started to look much paler - almost white in places - by this stage and were quite sensitive.  While the swelling was going down, the gums definitely still looked puffy and a bit spongy.  Some of the stitches were pulling and uncomfortable, but all manageable. 

Day 8-10

You might be able to have some stitches out at this stage, but mine were left in for another week.

I started to notice more white parts on my gums around the graft that looked like they were just hanging out - this freaked me out no end! This is apparently totally normal and you shouldn't poke or try to remove these parts, as they might (hopefully) eventually be incorporated into the gum tissue as the blood supply to the area improves.  Some bits can look really gross! 

You may be horrified and intrigued and try to get a good look at all the stuff going on in your mouth - try not to.  It won't help anything or give you clues about whether the graft is "taking" or not. 

This is definitely the ugly stage, and I found it hard to believe how much different it all looked just a few days later.

Day 11-14

This is the home straight now. You might get occasional twinges if you accidentally eat something that hits the graft area, but other than that eating is much easier.  

Those gross white bits (that you refrained from looking at...) should be starting to pinken up.  Don't poke at any that are remaining or you might knock them off prematurely.  However, some might also come off as part of normal sloughing, and that's OK too.

This is based on my experience - a sample of one - so it might not be representative for everyone. If you've been through surgery, or if you have a question, please comment below!