Periodontal surgery can take many forms.  In this page, we discuss the type of surgery to arrest and treat periodontitis.  These procedures are often also called "flap" or "osseous" surgery..

Periodontal or flap surgery in the simplest sense is designed to gain access to deeper areas of the roots of teeth and to clean the damaged areas.   The main advantage in using this procedure is that visual access is obtained and therefore the thoroughness of the debridement (cleaning) is improved.  

Flap surgery is  essentially similar to other various periodontal surgical procedures. The area to be treated will be numbed profoundly with a local anesthetic. After it is determined that the area is fully anesthetized, the surgery will open an access to the roots by elevating a "flap" of gum.   The roots are thoroughly cleaned to achieve the desired result.   Often a few sutures (stitches)  are necessary and usually the area is covered with a putty-like packing material to protect the site for a week.  Most patients are back to work the next day.

Deep pocket with calculus	Flap reflected to access calculus

Once the pocket is cleaned, the gum may be returned to its original level. This results in a clean root, but the deepened space is still present. Frequent cleanings by the hygienist are necessary to remove the plaque in the residual pocket that the patient cannot reach with flossing and brushing (See Periodontal Maintenance). Even when there is good oral hygiene and regular quarterly recalls, the bacteria may still continue to cause the pocket to become reinfected. When cosmetics are not a concern (on the lower teeth, the inside of the upper teeth, and the outside of the upper back teeth), the surgeon may elect to suture the gum down to where the bone has resorbed, reducing the depth of the space. If the space is reduced to 3 millimeters or less, the patient is able to reach the bottom of the space with daily brushing and flossing, eliminating the disease.

 

Gum sutured back to normal height, leaving a deepened space	Gum sutured down to bone to reduce residual space.

In the majority of advanced cases, the bacteria has caused the bone to resorb and become pitted. In these cases flap surgery gives access not only for root cleansing, but allows for recontouring of the bone itself. By performing this osseous surgery, and reshaping the bone to its natural scalloped shape, it is generally possible to eliminate moderate pockets.

The patient is then able to prevent recurrence of the disease by keeping the shallow space clean with brushing and flossing.

 

Bone recontoured after flap reflected.	Tissue sutured down to smooth bone to eliminate pocket.

Flap surgery is also needed if regeneration procedures are to be performed. Here the gum is reflected back to allow insertion of bone or guided tissue regeneration membranes (See Regeneration Surgery).

 

Flap reflected to allow bone implant	Flap resutured over bone implant
Flap reflected to insert membrane	Flap resutured over membrane

In summary, for most moderate and advanced cases, it is important to be able to reach far under the gum to treat the infection and diseased tissues. By using flap surgery, the periodontist is able to access these areas to provide the optimal care available. With today's medications, surgery should be painless with only a minimal amount of post-operative discomfort (See What to Expect from Surgery).