Periodontal flap surgery, explained.

The point of the surgery is to decrease pocket depth and establish healthy tissue in a shape you can actually keep clean at home, so the disease does not return. A pocket that is too deep to reach with a brush or an interdental brush will keep reinfecting, however well it is cleaned in the chair.

This is not the first step. Non-surgical treatment comes first, and for most cases it is enough. Surgery is for the sites that do not respond.

After non-surgical periodontal treatment, we re-measure. X-rays and clinical periodontal probing at that re-evaluation tell us which individual tooth sites still need surgical treatment, and which of those would benefit from regeneration as well.

It is site by site, not mouth-wide. Most people who need flap surgery need it in a handful of places, not everywhere.

1. Once the area is numb, a flap-like incision is made in the gum to reach the tooth roots and the bone around them.
2. Diseased tissue is removed from the pocket and the root surfaces are cleaned thoroughly, which is what clears the plaque and tartar driving the inflammation.
3. The bone is reshaped by drilling and scraping to a physiological, cleansable contour.
4. Where planned, regenerative materials are placed into the bone defects to restore function and stability.
5. The flap is returned to its original position and secured with sutures, and healing begins.

How long it takes depends on how many sites are being treated — anywhere from about 45 minutes to two hours. A periodontal re-evaluation follows after about three to four months, to assess how you have responded.

Where a bone defect can be seen directly during the flap operation, it can often be regenerated rather than simply cleaned. Three material types are used:

• Enamel matrix derivative — stem cells of porcine embryonic origin, which prompt the tissue to rebuild its original attachment.
• Barrier membranes — either resorbable collagen membranes made from porcine pericardium, or non-resorbable membranes made of PTFE or titanium.
• Bone substitutes — synthetic (alloplastic), or processed bone of bovine origin (xenograft).

Several of these are of animal origin. If that raises a dietary or religious question for you, raise it at the consultation rather than on the day — it is a reasonable thing to ask, and there are usually alternatives we can plan around.

Some minor bleeding is normal even though it is controlled during the procedure. Swelling peaks around day three or four. Stitches may be dissolvable or may need removing at your first or second post-operative visit. A soft diet for at least two weeks protects the site while it settles.

The full post-operative instructions for flap surgery cover rinsing, medication, diet and brushing through the healing period, and we give you the same sheet before you leave.