Periodontal Flap Surgery

Flap surgery is a periodontal operation in which the gum is gently separated from the tooth and bone and lifted back, so that the root surfaces and the bone can be seen directly. The section of gum that is lifted is called the "flap". The roots are cleaned while in full view, then the gum is put back in place and stitched. In dentistry it is also known as open flap debridement or open curettage.

This operation is not the first step in treating periodontitis. Deep cleaning comes first; flap surgery is considered only if deep pockets are still present once healing has been given time. We explain the overall step-by-step approach on the gum disease treatment page.

Why is deep cleaning sometimes not enough?

Deep cleaning works from inside the pocket, without seeing the root. That is enough when the pocket is of moderate depth and regular in shape. But the deeper the pocket, the harder it becomes for the instrument to reach the bottom and clean every point of the root surface. The closed method reaches its limits particularly with:

• Bleeding pockets of 6 mm or more at re-evaluation
• Bone loss in molars that extends into the area where the roots divide (the furcation)
• Vertical bone defects that form a crater in the bone beside a tooth
• Narrow areas where tartar can hide, such as grooves in the root surface

Tartar and bacteria left in these areas allow the disease to carry on silently. Flap surgery makes it possible to do the same cleaning, this time under direct vision.

The decision is not made on a single number. Pocket depth, bleeding, tooth mobility, the shape of the bone loss and the tooth's importance in the mouth are assessed together. Surgery is easier to justify to save a tooth that supports a bridge or a denture; for a tooth that has lost most of its support and is very loose, an operation often does not change the outcome.

Who should not have it, or should wait?

We do not operate on a patient whose oral hygiene has not yet reached an adequate level. If plaque builds up in the area after surgery, the gain is soon lost, so good home care has to be established first.

In situations such as poorly controlled diabetes, heavy smoking or a recent serious heart problem, the operation may be postponed or the plan may change. Smoking makes surgical results markedly worse, and the difference is large particularly in procedures aimed at gaining bone. You need to tell us in advance about the medicines you take, especially blood thinners and medicines for osteoporosis.

How is the operation done?

1. Numbing. Local anaesthetic is given to the area, and you do not usually feel pain during the operation. If you are very anxious, we can discuss sedation.
2. Lifting the gum. Fine incisions are made along the gum margin, and the gum is separated from the bone and lifted.
3. Cleaning. Tartar and inflamed tissue on the roots are removed under direct vision, and the root surfaces are smoothed.
4. Reshaping or regenerating the bone. Irregular bone edges are smoothed if needed. In suitable vertical bone defects, graft material, a protective membrane or biological materials that support healing can be placed; this is called regenerative surgery.
5. Stitching. The gum is positioned back where it was, or slightly lower to reduce the pocket, and stitched.

One area, meaning a quarter of the mouth or a smaller part, usually takes 1–2 hours. If more than one area needs treatment, the visits are planned a few weeks apart.

How does healing go?

• In the first 24 hours, a cold compress applied on and off to the outside of the face reduces swelling.
• Do not smoke, at least while you are healing; smoking increases the risk of the stitches opening and of infection.
• Do not bite hard or crunchy food with the operated area.
• If the swelling increases, or you have a fever or bleeding that will not stop, contact us straight away; if you are no longer in İzmir, also see a dentist near you without delay.

Antibiotics are not needed after every operation; the dentist decides based on the case and the procedure carried out.

How will my teeth look after surgery?

To reduce the pocket, the gum often ends up positioned slightly lower than before. As a result, the teeth may look longer, triangular gaps between them may become more noticeable, and the exposed roots may be sensitive to cold. This is a known consequence of the surgery and should be discussed beforehand. If appearance is the main concern on the front teeth, the technique is chosen accordingly; for any remaining recession, gum recession treatment can be considered later.

What are the alternatives?

For bleeding pockets of moderate depth, repeating deep cleaning is often enough; flap surgery is not needed for every remaining pocket. For teeth that have lost a very large part of their bone support, extraction followed by an implant or a denture can be discussed instead of surgery. But in someone who has had gum disease, the area around an implant carries the same risk; an implant does not replace periodontal maintenance. At our clinic in İzmir, we make this decision with you, going through the re-evaluation measurements and X-rays together.

The cost depends on the number of areas to be operated on, whether regenerative materials are used and whether sedation is needed; you receive a written, itemised quote after the examination.