What is Gum Flap Surgery?

Periodontal flap surgery is recommended by dentists in cases of moderate to severe periodontitis, when the non-surgical treatments of periodontal disease have failed to control the bacterial infection and reduce the periodontal pockets depth.

The first steps in gum disease treatment is improving the patient’s daily oral hygiene routine. For common cases of gingivitis (mild gum disease), better oral hygiene, antimicrobial medicines in the form of mouth rinses, and tooth scaling and root planing are usually enough to stop the bacterial growth and reverse the effects of gum disease. A good evidence of a successful treatment of gum disease is the depth of periodontal pockets returning to normal values <3mm.

In patients with periodontitis when the pockets are deeper, tooth scaling and root planing may not succeed to reduce adequately the depth of periodontal pockets. In these cases the periodontist will recommend gum surgery as the next step in fighting periodontal disease and periodontal flap surgery for pocket depth reduction is usually the first option.

Periodontal pockets are areas between the teeth roots and gums or bone, which are created when gums get detached from teeth. Food debris and bacteria get trapped in periodontal pockets where bacteria find a favorable environment to grow and start destroying the periodontal tissues, gums and bone.

If the depth of periodontal pockets is kept below 3mm, careful tooth brushing and flossing can remove most of the bacteria and debris from inside the pockets. But if the depth is over 3mm (in severe periodontitis it can reach 7-10 mm) there is no way that the patient can clean the trapped bacteria.

Deep pocketing can prevent gingival and bone tissues from fully healing and staying healthy. Over time, periodontal pockets become continuously deeper, trapping even more bacteria, resulting in further bone and tissue loss. Finally teeth lose their support and fall out or have to be extracted.

Before a gum surgery patients must have taken measures to improve their oral hygiene routine. It is also recommended that patients have a professional dental cleaning including tooth scaling and root planing.

Periodontal flap surgery is generally performed by a periodontist, a dental specialist who specializes in diagnosing and treating conditions that affect the gums and supporting bone.

• A local anesthetic is used to numb the gums and reduce discomfort during the surgery.
• Vertical incisions are made on the gums on both sides of the tooth/teeth to be treated.
• The periodontist uses a scalpel to separate the gums from the teeth. The gums are then folded back, forming a ‘flap’, in order to expose the underlying teeth roots and jaw bone. The dentist has now access to the full depth of the periodontal pockets.
• Dental plaque bacteria and dental calculus are scraped away from the teeth surface in a way similar to that during tooth scaling and root planing. The dentist will also remove any infected or diseased tissue.

In some cases, bone damage can create irregular bone surfaces that provide difficult to clean areas for the bacteria to hide and grow. These abnormalities can be smoothed during gingival flap surgery with an osseous surgery procedure called osseous recontouring, to allow the gum tissue to reattach to healthy bone. If there is excessive bone loss the periodontist may perform a bone graft to restore the lost bone.

After the procedure is complete, the gingival flaps are placed back in touch to the teeth and stitched back into their original position. The stitches can be either dissolvable or they have to be removed a week to 10 days after the surgery. The surgical site is usually covered with a periodontal pack or dressing to allow healing.

Mild to moderate discomfort is expected after the procedure, especially if the pocket depth reduction procedure involves several teeth.

• Periodontists will usually prescribe some pain reliever after the gum surgery.
• The periodontist will also prescribe an antimicrobial mouth rinse containing chlorhexidine for some days to help control dental plaque bacteria.
• If there is swelling, it can be reduced by applying an ice pack to the outside of the face in the treated area.
• The mouth must be kept as clean as possible to avoid any infection of the surgical site. Careful oral hygiene with regular tooth brushing and flossing is very important.
• If a periodontal dressing is used, the patient should avoid brushing that area to prevent taking it out of place, otherwise the surgical site should be cleaned gently using an extra soft toothbrush.
• Patient should avoid smoking, eat soft foods and avoid sucking motions such as when using a straw to drink.
• A visit to the periodontist is planned after 7 to 10 days to examine the progress of healing and remove any stitches. Full healing may take 2 to 4 weeks.

After the surgery, there may be some bleeding and swelling. The periodontist should be contacted if there is excessive bleeding, swelling, pain or signs of infection.

After treatment is complete, the gumline will most likely be lower, leaving more of the tooth exposed. If part of the root is exposed this could cause tooth sensitivity problems. Aesthetic appearance may also be affected because treated teeth will look longer than before.

Gums in the area of the flap surgery may have increased risk of receding over time, causing teeth sensitivity and making teeth more susceptible to developing cavities in the roots area.

Gingival flap surgery to reduce the depth of periodontal pockets is recommended by periodontists for the treatment of moderate or advanced periodontitis especially if non-surgical treatments (tooth scaling and root planing, antibiotics) have not eliminated the gum infection.

The pocket depth reduction achieved with gum flap surgery is considered by periodontists as one of the critical factors in eliminating the bacterial infection, controlling the progress of periodontal disease and maintaining a healthy smile.