Flap/Osseous Surgery

Traditionally, gum disease is treated by eliminating or reducing the pockets that have developed in the diseased gum tissues. The deeper contaminated root surfaces are cleaned, infected gum tissue is removed and the uneven or irregular architecture of the remaining jaw bone is re-shaped to a more ideal contour. This technique may be utilized for the treatment of gum disease along with new and more sophisticated procedures, which can result in growing new bone in areas that have suffered severe damage from the disease process.

By far the most common surgery used in periodontal therapy is flap surgery. Moderate to advanced periodontal disease involved gum pockets (See What Is Periodontal Disease?) that are too deep to clean without reflecting back the gum tissue for access. Without this access, deep calculus and plaque cannot be removed from the root, and the disease will progress. This surgical cleaning procedure is often called open flap curettage.

Deep Pocket graphic

Deep pocket with calculus
flap reflected graphic

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.

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 graphic

Gum sutured back to normal height, leaving a deepened space
gum sutured graphic

Gum sutured down to bone to reduce residual space

Advanced Cases

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.

bone recontoured graphic

Bone recontoured after flap reflected
tissue sutured graphic

Tissue sutured down to smooth bone to eliminate pocket

Regeneration Procedures

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 graphic

Flap reflected to allow bone implant
Flap resutured over bone implant graphic

Flap resutured over bone implant

Flap reflected to insert membrane graphic

Flap reflected to insert membrane
Flap resutured over membrane graphic

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 todays medications, surgery should be painless with only a minimal amount of post-operative discomfort.