What are the indications for Periodontal (gum) flap surgery?

From the Guidelines

Periodontal flap surgery is indicated for patients with moderate to severe periodontitis who have not responded to non-surgical treatments, have deep periodontal pockets, significant bone loss, or require regeneration of lost periodontal tissues. This procedure is specifically recommended for patients with deep periodontal pockets (typically greater than 5mm), significant bone loss, furcation involvements, or persistent inflammation despite initial therapy 1. The surgery is also indicated when better access is needed to remove subgingival calculus and infected tissue, to reduce pocket depths, or to regenerate lost periodontal tissues. Additionally, it may be necessary for patients requiring crown lengthening procedures or to address gingival recession.

Some key points to consider when deciding on periodontal flap surgery include:

• The patient's overall health and ability to heal
• The extent of periodontal disease and bone loss
• The presence of furcation involvements or other complex anatomical features
• The need for regeneration of lost periodontal tissues
• The patient's compliance with oral hygiene practices and maintenance care

The use of recombinant human growth factors such as rhPDGF-BB has been shown to enhance periodontal regeneration and improve clinical outcomes in periodontal flap surgery 1. The combination of rhPDGF-BB with beta-tricalcium phosphate has been shown to be a safe and effective treatment for periodontal intrabony defects, with significant gains in clinical attachment level and linear bone gain.

Before proceeding with flap surgery, patients should demonstrate good oral hygiene practices and compliance with maintenance care, as these factors significantly impact long-term success. Post-operatively, patients typically require analgesics for pain management, chlorhexidine rinses to control plaque, and regular follow-up appointments to monitor healing and ensure long-term stability.

From the Research

Indications for Periodontal Flap Surgery

The decision to perform periodontal flap surgery is based on several factors, including the depth of periodontal pockets, the extent of attachment loss, and the patient's overall oral health.

• Periodontal flap surgery is typically indicated for sites with deep pockets, as it allows for better access and visualization of the affected area, enabling more effective debridement and repair 2, 3.
• The "critical probing depth" value, which is the depth at which surgical therapy becomes more effective than non-surgical therapy, has been reported to be around 4.2 mm for scaling and root planing used in combination with modified Widman flap surgery 2.
• Surgical therapy has been shown to result in greater probing-depth reduction and clinical attachment gain in initially deep pockets compared to non-surgical therapy 3.
• However, in sites with initially shallow pockets, surgical therapy may result in more attachment loss than non-surgical therapy 2.
• The choice of surgical technique may have limited influence on changes in clinical attachment gain, but thorough mechanical debridement and optimal plaque control are essential for successful periodontal therapy 3.

Comparison with Non-Surgical Therapy

• Studies have compared the outcomes of periodontal flap surgery with and without initial scaling and root planing, and found that combined therapy resulted in greater probing depth reduction and clinical attachment gain 4.
• A review of nonsurgical and surgical periodontal therapy highlighted the importance of thorough mechanical debridement and optimal plaque control for successful treatment, regardless of the method used 3.
• Another study compared the long-term outcomes of periodontal regeneration with access flap surgery and found that regeneration provided better long-term benefits, including no tooth loss, less periodontitis progression, and less expense from re-intervention over a 20-year period 5.

Considerations for Treatment

• The decision to perform periodontal flap surgery should be based on a thorough evaluation of the patient's periodontal status and overall oral health.
• The patient's ability to maintain good oral hygiene and comply with supportive periodontal care is crucial for the success of periodontal therapy, regardless of the method used 2, 3.
• The choice of surgical technique and the decision to use adjunctive therapies, such as systemic antimicrobials, should be based on the individual patient's needs and the specific characteristics of the periodontal disease 3, 6.