Gum Tissue Surgery (Flap Operation)

What is Gum Surgery (Flap Operation)?

Flap operations, part of the periodontal specialty in dentistry, come into play when closed cleaning methods (such as dental scaling and curettage) are insufficient for deep tissue infections. When the pathological pockets that form between the tooth and the gum exceed a certain depth, the dentist’s instruments cannot reach the bottom of these pockets and remove all the bacteria. The remaining microbial deposits continue to erode the jawbone. The flap operation provides the dentist with a direct view by allowing the tissue to be surgically opened like a flap. This way, root surfaces and bone defects can be inspected visually and cleaned thoroughly.

The planned flap surgeries at Avrupadent clinics, serving the İzmir location, aim to protect the supportive tissues that hold the teeth in the jaw and to halt bone loss. Despite being a surgical intervention, it is based entirely on tissue repair and the philosophy of saving the teeth. After the physician cleans the inflamed areas, they tightly adapt the gum to the neck area of the tooth; thus, the biological foundation necessary for the patient to maintain chewing function with their own natural teeth for many years is recreated.

In Which Situations is Flap Surgery Applied?

When a patient is in the initial stage of gum disease (gingivitis), surgery is not required. However, when the disease progresses to the bone, and the expected healing in the tissues does not occur after routine cleaning sessions, advanced surgical planning becomes necessary. The main situations where surgery is considered to stop the inflammation from progressing to the root tip are as follows:

How is Gum Surgery Performed?

Gum surgery; involves local anesthesia of the surgical area, surgical tools separating the gum tissue from the root and bone surface, scraping away inflamed tissue from the exposed root surface, and finally bringing the gum back to its original position and suturing it.

During the procedure, local anesthetic solutions are applied to the patient’s gums to ensure clinical comfort. Once complete numbness is achieved, the physician makes microscopic incisions from the neck area of the teeth, lifting the gum away from the bone like a flap. This opened tissue allows for complete access to infected bone craters and root surfaces visible in X-rays but unreachable from the outside.

Using special periodontal instruments (curettes) and ultrasonic devices, the root surface is thoroughly cleaned (root planing). Inflamed (granulation) tissue is completely removed from the area. If the architecture of the jawbone has been compromised, the bone is shaped using appropriate diamond burs. Once the cleaning phase is completed perfectly, the separated gum tissue is sutured tightly around the neck of the tooth using micro sutures, concluding the procedure.

Who May Be Suitable for Flap Surgery?

This procedure is one of the last barriers aimed at saving the tooth for patients diagnosed in advanced stages of the disease. It is typically indicated in adult individuals aged 30 and above who have experienced bone loss. The presence of systemic diseases is carefully examined to determine the patient’s eligibility for surgical procedures. While controlled chronic conditions do not pose a barrier to the operation, bleeding disorders or uncontrolled systemic conditions require consultation with a physician to outline a clinical roadmap.

In patients who smoke, the healing of wounds and the long-term protective effect of the operation significantly decrease; therefore, doctors request the limitation of smoking prior to performing the procedure. For patients with inadequate personal oral hygiene habits, surgical intervention alone cannot provide lasting protection; thus, adopting hygiene training is a suitability criterion for the patient.

How is an Evaluation Conducted Before Gum Surgery?

Clinical evaluation before the procedure; involves the millimetric measurement (sond) of the depth of the gum pockets with a periodontal probe, assessment of the degrees of mobility (looseness) in the teeth, and detection of the amount of bone loss in the jawbone using radiological methods.

Before the operation, the progression of the gum disease in the mouth is regionally mapped out to see which teeth are affected. The dentist places a blunt measuring tool (periodontal probe) into the gum pocket to record the depth. Depths between 1 and 3 millimeters are considered physiological, while pockets of 5 millimeters and above indicate a need for surgical intervention. The bleeding profile of the tissue is also assessed during these measurements.

In the radiological examination, periapical (small detail) X-rays or panoramic films are used. It is determined whether the bone loss occurred along a horizontal or vertical line. Vertical bone losses appear as crater-like cavities, which are quite amenable to repair by adding artificial bone powder (graft) during surgery. The surgeon plans the surgical strategy based on these anatomical data.

How is the Flap Operation Process Planned?

Process planning; in the first stage, conducting non-surgical surface cleanings and providing oral hygiene education, monitoring the initial tissue responses, and subsequently scheduling surgical appointments regionally for areas that do not heal (maintaining depth).

In the field of periodontology, no surgical procedure is initiated in the first session (except for emergency abscesses). In Avrupadent process protocols, the disease is attempted to be controlled by starting with a phase called “Phase 1 Treatment”. In this phase, tartar is cleaned, and the patient is included in the routine of proper brushing and using interdental floss. The reaction of the tissues to the initial cleaning is re-evaluated approximately 3-4 weeks later.

As a result of the re-evaluation, if it is determined that pockets over 5 mm have not closed, a surgical phase is planned. Surgeries are generally not performed on the entire jaw at once to maintain patient comfort; instead, the jaw is divided into four quadrants (regions), and procedures will be organized on alternating days, with one or two regions treated under local anesthesia during each session.

What Stages are Followed in Gum Surgery?

Clinical operation consists of precise surgical steps to cleanse the infected area and ensure the tissue reattaches to the bone in a healthy position. The stages observed are as follows:

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• ▪ Incision (Cut) and Flap Elevation: The gum tissue is carefully cut from the neck of the tooth with a scalpel (blade) to create a window in the bone tissue.

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• ▪ Debridement and Root Planing: Scraping of the soft inflammatory granulation tissues filling the intra-bony defects and leveling the hard tartar deposits on the root surface.

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• ▪ Bone Shaping (Regeneration): If there is resorption and irregularity in the bone, small adjustments are made; in suitable cases, bone powder and membrane are placed to stimulate new bone formation.

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• ▪ Suturing (Stitching): The cleaned area is covered by positioning the flap (gum) back against the tooth and securing it with fine suture threads.

What to Pay Attention to Before Flap Surgery?

Things to Consider Before Surgery; it is essential to fully adhere to the mouth care rules provided by the doctor (regular brushing), to arrive at the appointment with a full stomach, and to consult with the physician regarding the adjustment of any blood-thinning medications being used.

Before undergoing a surgical procedure, minimizing the number of surface bacteria in the mouth is crucial to reduce the risk of infection. The patient should carefully brush their teeth on the morning of the surgery and use dental floss to clean between teeth. To ensure that the blood sugar level does not drop during local anesthesia, patients are advised to be lightly fed at the clinic.

Providing complete and accurate information to the dentist about the patient’s general systemic condition (heart disorders, thyroid problems, etc.) and regular medications is critical for the management of the medical process. In order to ensure proper control of bleeding, medication adjustments are planned at least a day before the operation based on the doctor’s advice.

What Should Be Considered After Flap Operation?

Post-procedure precautions; during the first 24 hours, apply cold compress (ice) to the procedure area, avoid hot, acidic, and hard foods, do not brush the stitched area, and refrain from consuming tobacco products during the healing phase.

The tissues in the surgical area are in the repair phase for the first few days; therefore, mild edema (swelling) in the cheeks and very minimal leakage in the form of blood are physiologically normal. On the first day, applying ice intermittently from the outside will help keep swelling to a minimum. To avoid disrupting the clot, one should refrain from actions like sucking, gargling, and using straws to drink.

Do not chew on the side where the operation was performed; prefer soft and warm foods. Additionally, prescribed antibiotics or pain relief medications should be taken as directed without interruption during the specified time periods. Do not brush the sewn area; instead, maintain the hygiene of that area with prescribed chlorhexidine-based chemical mouthwashes, using gentle movements.

Which Gum Diseases Are Evaluated for Gum Surgery?

Gum surgeries are generally assessed in clinical situations where the disease has progressed beyond the superficial level and started to damage the bone tissue. The main diagnoses that require intervention are as follows:

Disease Type	Clinical Table and Surgical Reason
Chronic Periodontitis	Slowly progressing yet continuously ongoing bone loss; the need for cleaning deep pockets visually.
Aggressive Periodontitis	A rapidly destructive inflammation observed in younger individuals, genetically predisposed, which can be halted through surgical debridement.
Gum Overgrowth (Hyperplasia)	The shaping of excessive tissue that covers the teeth due to drug use or systemic reasons, forming pockets.

How are Deep Gum Pockets Evaluated with Flap Surgery?

The evaluation of deep pockets; is based on the principle of surgically accessing and cleaning cavities that are deeper than 5 millimeters, where the bristles of the toothbrush or the tips of closed curettage instruments cannot reach, and where bacteria continue to produce.

A gum pocket is a pathological gap between the tooth and the soft tissue surrounding it. In a healthy tooth, this distance is 1-3 millimeters, and when one brushes their teeth, the bristles can reach this depth for cleaning. However, as the disease progresses, this depth can reach up to 6, 7, or even 10 millimeters. Aggressive bacteria that thrive in anaerobic environments settle in these deep pockets. It is physically impossible for the toothbrush or rinses to affect these dark depths.

The primary purpose of flap surgery is to overcome this physical obstacle. When the gum tissue is surgically opened, the deep “pocket” structure is eliminated. The doctor accesses the area where inflammation is present in the bone. At the end of the procedure, while the tissue is being stitched back, the depth of the pocket is reduced to healthy, manageable (1-3 mm) limits that the patient can self-clean.

How Does the Healing Process Progress After Flap Surgery?

The healing process; in the first week, the surgical wound edges come together (primary union), sutures are removed around 1-2 weeks, and during the continued process, the adaptation of the gum tissue by shrinking tightly to the tooth root is completed at the cellular level.

In the first 2-3 days after the operation, there is tissue swelling. The formation of a white/yellowish fibrin (wound cover) layer over the sutured areas is a normal part of healing. The stitches used by the doctor are mostly non-dissolvable and are removed with a short clinical appointment after about 10-14 days.

After stitches are removed, the tissues enter the main repair phase. Since the inflamed and swollen (edematous) gums have been cleaned, they lose volume and shrink as they heal. This shrinking may cause the patient to feel that the gaps between the teeth have opened a bit or that the teeth have elongated somewhat. This optical change is actually a positive clinical indicator that demonstrates the subsiding of inflammation and that the tissues have returned to a healthy and firm (fibrotic) form after clearing the infection.

How Should Oral Care Be Performed After Flap Surgery?

Oral care routine; during the first two weeks following surgery, cleaning the surgical area without using a toothbrush is achieved by chemical mouth rinses containing chlorhexidine, and after stitches are removed, returning to mechanical cleaning with extra soft toothbrushes and inter-dental brushes.

It is essential to protect the surgically intervened area from mechanical trauma until the stitches are removed. The patient may continue to brush other areas of the mouth as usual, but to prevent plaque formation in the surgical area, they should only use the antibacterial liquids recommended by their physician in the morning and evening by rinsing. Using a hard toothbrush in the early period can cause stitches to break and the wound to open.

Once the tissues are harvested and the tissue stability is ensured (approximately after the second week), a gentle squeezing procedure is initiated with post-operative surgical tools. The main factor ensuring the longevity of the treatment is the cleaning of the triangular gaps (embrasures) that form between the teeth with appropriately sized interproximal brushes at least once a day after healing. Without interproximal hygiene, there is a risk of disease recurrence.

What Diagnosis and Planning Methods are Used in Gum Surgery?

Diagnosis and planning methods; include measurements of physical pocket depth (probing), recording bleeding indices in the tissue, and two-dimensional (periapical/panoramic) and three-dimensional (tomography) radiological imaging tools detailing the anatomy of the bone resorption.

While the visually performed examination provides a superficial idea about the severity of the disease, the actual destruction occurs beneath the tissue, in the bone. The physician analyzes by mapping the horizontal and vertical levels of the bone surrounding the teeth on X-rays whether he can place bone powder (graft) or a membrane in that area during surgery. Radiographic findings provide guidance on the shape of bone resorption (crater, single-walled, double-walled defects).

During the planning phase, all these pocket depths are worked on the “periodontal record form.” This data is used as a comparative point (baseline value) to objectively measure how well healing is maintained after surgery. The physician determines the boundaries of the surgical area by intersecting these radiological and physical data.

How Long Can Flap Surgery Last?

Duration of the operation; While it can vary depending on the width of the area to be treated (number of teeth to be operated on) and additional surgical procedures to be performed (such as bone grafting), it usually takes between 45 minutes and 1.5 hours for one half of the jaw.

The physician prefers to divide the mouth structure into four quadrants (like a clock). Intervention is made in specific areas such as the upper right or lower left in a single session. During this time, procedures such as anesthesia, making incisions, cleaning all root surfaces in microscopic detail, and suturing are carried out in a concentrated manner.

If, in the opened area, not only is inflammation cleaned but also artificial bone graft (bone powder) and collagen membranes are to be placed with the aim of reconstructing the resorbing bone (regenerative surgery), the process of harmonizing and stabilizing these additional materials may extend the duration somewhat. In order for the procedure to be completely pain-free and comfortable, a meticulous approach without rushing is adopted in the working area.

Why Is Control Examination Important After the Flap Operation?

The clinical importance of control examinations; in the first weeks, it is to prevent bacterial accumulation in that area by removing the stitches from the wound lips, and in the following months, it is to objectively monitor whether the pocket depths have decreased and whether tissue compression is occurring.

In the field of periodontology, no treatment is considered “finished” at the moment the patient leaves the clinic. The clinical benefit of a surgery becomes apparent through cellular adaptation that emerges months after the wound has closed. During the stitch removal session, the state of primary healing on the surface is examined, and the patient is practically shown how to implement auxiliary cleaning education.

The primary control appointments conducted between 3 to 6 months after surgery involve measuring the initially deep pockets of 6-7 millimeters again. It is confirmed that in a healthy tissue reaction, these pockets will shrink and form tight, healthy grooves of 2-3 millimeters. These checks are critical steps in preventing the risk of recurrence.

Can Gingival Surgery Be Planned Together with Other Periodontal Treatments?

Treatments planned in coordination; include guided tissue regeneration (GTR) using bone powder and tissue membranes during the surgical session, cosmetic crown lengthening procedures, and simultaneous interventions aimed at gum recession (graft surgery).

The mouth is an ecosystem, and the disease process rarely remains limited to a single specific issue. The surgical flap opened to clean the inflammation allows the physician to intervene in the anatomical structures of that area in many respects. For instance, in a case with deep inflammation and asymmetrical gum forms, the gum levels can be aesthetically corrected to align the crown lengths at the same time during the flap operation (a combination of gingivectomy/gingivoplasty).

However, the resorption crater in the jawbone encourages the reconstruction of the lost support by adding sterilized bone grafts (powders) from outside instead of just filling it with blood. This multidisciplinary surgical approach provides comprehensive support so the patient can maintain healthier retention in the jaw without having to extract their own teeth.

What Treatments Are Evaluated Before the Flap Operation?

Treatments that must be applied before the operation; the ultrasonic removal of all dental calculus above and below the gum line (scaling) and the root surfaces being thoroughly cleaned using hand instruments (subgingival curettage).

Gum surgery is not the first choice (initial step) of treatment. It is essential to reduce (alleviate) the swelling and acute inflammation in the tissue before starting any surgical procedure. This non-surgical initial phase is referred to as “Phase 1 Periodontal Treatment.” Your doctor will remove the primary microbial load from the root surface using closed cleaning methods during this process.

When pre-cleaning is done, some tissues may heal on their own by tightening, and the swellings will subside. The reduction of swelling allows for the identification of true and permanent pocket depths. Immediate surgical decision on an edematous (swollen) tissue can lead to unnecessary interventions. If at the control performed about 4 weeks after initial treatment there are deep pockets that do not close and are persistent, only surgical access (flap) to those areas will be evaluated.

What Precautions Should Be Taken to Maintain Gum Health After Flap Surgery?

Long-term health maintenance; is possible by strictly adhering to the hospital’s “Supportive Periodontal Therapy” program, having the clinical scaling performed at the intervals of 3, 4, or 6 months as instructed by their doctor, and daily removing personal plaque at home.

Periodontitis is a chronic inflammatory disease that needs to be controlled, like diabetes or hypertension. Surgical operation improves the disease and restores the tissue to a healthy form; however, if the patient neglects their brushing and flossing routines, the same bacterial plaque (tartar) can lead to a recurrence of the disease within a few months as it seeps under the gum.

After the operation, the formation of slight gaps between the healed gum tissues is physiological. These expanding intervals cannot be cleaned with standard dental brushes. The use of brushes with appropriate sizes at least once a day is the most important line of defense that ensures the surgical success remains stable for many years.