Bone Grafting and Sinus Lift

When a graft may be considered

• The height or width of bone where the implant is planned is not enough
• In the back of the upper jaw the sinus sits low, with too little bone beneath it for the length of the implant
• The socket is to be preserved in the same session as an extraction
• The ridge of the jaw has thinned where a tooth has been missing for a long time
• Gum disease has left a limited defect in the bone; not every defect can be grafted

When another step comes first

• Active infection and untreated gum disease. These are treated first.
• Uncontrolled medical conditions. If blood sugar is unstable or there is an undiagnosed problem, surgery is postponed.
• A jaw that is still growing. In young patients, implants and any graft for them are postponed until growth is complete.

What is associated with higher risk

The figures below come from studies of implant loss. We have no figure that measures graft success directly.

• Smoking. A 2020 review compared people smoking more than 20 cigarettes a day with non-smokers. Implant loss was about 2.5 times as likely per implant¹, and about 4 times as likely per patient. In that review the risk rose with the number of cigarettes, and no level of smoking was shown to be free of extra risk. Smoking is also associated with poorer wound healing.
• Bone-strengthening medicines. In a 21-study review, implant loss in people taking bisphosphonates was about 1.7 times more likely per implant². Jaw osteonecrosis was about 3.5 times more likely per patient. The per-patient analysis of implant loss found no significant difference. The same review could not make a reliable risk estimate for denosumab, so we give no figure for it. The certainty of the evidence is very low. For people taking high-dose bisphosphonates or denosumab as part of cancer treatment, surgery is usually not appropriate. Whether the medicine is given by drip, by injection or by mouth does not on its own decide the risk. The decision is made with your oncology team. Do not stop or pause one of these medicines without asking the doctor who prescribed it.
• Diabetes. The findings are mixed. Two of three reviews found no significant difference in implant loss (2021 review³; 2016 review⁴), and one found a higher rate⁵. The 2021 review, in type 2 diabetes, says its reassuring result depends on strictly maintained oral hygiene. All three found more bone loss around implants in people with diabetes.
• A history of periodontitis (gum disease that has damaged the bone around the teeth). Across 14 prospective studies the rate of implant loss was about 1.75 times higher⁶ (a hazard ratio). Surgery is not done while the disease is active.
• Radiotherapy to the head and neck. Wound healing is impaired in irradiated bone, and there is a risk of bone death. We ask for the area and dose of your radiotherapy, and plan with your oncology team.

What can be considered instead

• Short implants. A Cochrane review found that in a shrunken (resorbed) lower jaw, short implants appear to be a better option⁷ than a vertical bone graft. The review rests on few trials with few patients. Case selection, bone quality and chewing forces are assessed.
• Tilted implants. In a jaw with no teeth, placing the back implants at an angle may reduce the need for a graft in some patients. The details are on the All-on-6 page.
• Zygomatic implants. When very little bone is left in the upper jaw, implants anchored in the cheekbone may be considered. This is larger surgery with its own risks; it is explained at the consultation.
• A bridge on your own teeth, or leaving the gap. Where one or a few teeth are missing, a bridge on the neighbouring teeth needs no graft. A conventional bridge needs those teeth to be reduced to hold it. For some single-tooth gaps, an adhesive bridge bonded to the back of a neighbouring tooth needs very little or no grinding. Leaving the gap is also a choice. These options are compared on our dental implants page.
• A removable denture. If surgery is not wanted or not suitable, a denture is an option.

Suitability is decided by an examination, a 3D scan and your medical history. A plan given from photographs or from an X-ray sent from home is not final; it is a preliminary assessment.

Sometimes. If there is enough bone, no graft is needed; and if there is not, a graft is not the only route. The options are considered in order: an implant without extra surgery, a design that needs less surgery, then a graft.

A sinus lift without graft material has also been reported. A review of 16 articles reported implant survival at 48 to 60 months of follow-up. It was 96 per cent without graft material⁸ and 99.6 per cent with a biomaterial, counted per implant. The review's published summary reports no direct statistical comparison of these two rates; we could not read the full text. So the difference cannot be counted as a proven advantage, and nor can the opposite.

No single technique or material has been shown to be superior for every patient and every outcome. A Cochrane review states that the most effective technique remains unclear⁷. The same review reports differences in single comparisons, such as bone gain and patient preference. A review of sinus floor augmentation found no significant difference⁹ in implant loss between your own bone and bone substitutes. Finding no difference in implant loss does not mean the materials are equivalent in every respect. If a material is presented to you as "the best", ask for the reasoning on your own scan.

Where the graft material comes from is also part of your decision. It can be taken from your own bone or prepared from a human donor or an animal source (cattle or pigs). It can also be fully synthetic. Covering membranes can also be of animal origin. For some patients this is decisive, for religious or personal reasons. Before you consent, you are told which graft and which membrane will be used and where they come from. You are also told the alternatives, and whether they need to be removed later.

This is the usual sequence. Which method is chosen depends on the scan and the shape of the defect. How the stages fit around travel is covered in "If you are coming from abroad" below. The number of visits, the gaps between them and the waiting periods are given in your written plan; they vary from patient to patient.

Risks

The figures below come from published studies, not from our own records.

• A tear in the sinus membrane. The membrane often tears during a sinus lift. A review of 10 studies looked at sinus lifts through a side window with graft material. The average tear rate was 29.42 per cent¹⁰. The earlier studies it cites report 16 to 56 per cent. A tear is usually repaired in the same session. Depending on its size and how reliable the repair is, the procedure may be stopped and planned again once the membrane has healed. Implant survival was 97.1 per cent after a repaired tear and 97.7 per cent with no tear. The difference was not significant. Some of its studies describe problems after surgery, such as sinusitis. The review does not compare them between torn and intact membranes. So it does not show that a tear has no drawbacks.
• Complications with vertical augmentation (building the bone up in height). A Cochrane review of 13 randomised trials states that complications are common, especially with vertical augmentation. Compared with short implants, the odds ratio for complications was 4.97⁷, per patient. This does not mean that the absolute risk is five times higher. The review rests on few trials with few patients, so this estimate is uncertain. In the same review the difference in implant loss was not significant.
• Infection and the graft not taking. Infection can develop at the graft site, stitches can open and a membrane can become exposed. If that happens, part or all of the graft may be lost and the procedure may need to be repeated.
• Graft particles coming out. In the first weeks, small hard particles may come out through the gum. A bad smell, discharge or increasing pain may be a sign of infection.
• The donor site. If a block of your own bone is taken, a second surgical site is opened. It too brings pain, swelling and a scar. Depending on the site, it can also bring numbness and a longer recovery. The risks of the site proposed for you are explained before you consent.
• The sinus area in the upper jaw. Sinusitis, a nosebleed or an opening between the mouth and the sinus can develop. We have no sourced figure for how often these happen.
• The nerve in the lower jaw. Because the nerve canal is close in the back of the jaw, the lip and chin may feel numb for a while and, rarely, permanently.
• Medication-related death of jaw bone (osteonecrosis). In patients taking bisphosphonates, the risk of jaw osteonecrosis after surgery was found to be higher. The review cited on this page gives no reliable estimate for denosumab. If you take either medicine, tell us about every medicine you take.
• A limit on flying. A 2023 narrative review suggests waiting at least two, and ideally six, weeks¹¹ after a sinus lift before flying. That assumes no pain, swelling or bleeding at the treated site. This changes the travel plan.

Benefits

• The aim is to gain the bone an implant needs, so it can be placed in the planned position and at the planned length. Sometimes the bone gained is not enough, and a further graft or a different plan is needed.
• Implant loss after sinus floor augmentation has been reported as low. In 11 prospective studies with at least five years of follow-up, annual loss was 0.43 per cent per implant⁹. In these studies the remaining bone height was 6 millimetres or less, and the side-window technique was used.
• The same review found no significant difference between your own bone and bone substitutes. Nor did it find a difference between placing the implant in the same session or later. Finding no difference does not show that the methods are equivalent for every patient; the findings are limited to the group of patients described above.
• Preserving the socket at the time of an extraction may limit bone shrinkage, though a further graft may still be needed later.

These rates are outcomes observed in studies, not promises. They are averages of studies from different countries and different groups of patients. What happens in your case depends on your bone, your habits and your care.

The first days

• Swelling and bruising usually increase over the first two to three days, then settle. Use cold packs and the medicines prescribed.
• Choose soft, lukewarm food, and avoid chewing on the graft site.
• If you wear a removable denture, ask whether and when you can wear it over the graft. Have it adjusted so that it does not press on the healing area.
• If the sinus area was treated, do not blow your nose or drink through a straw, and if you sneeze, keep your mouth open. These rules reduce pressure changes on the sinus membrane. Follow them for as long as your written instructions say, not only in the first days.
• Keep brushing; clean the graft site gently, the way your dentist shows you.
• Smoking is associated with poorer healing. At the least, do not smoke during the healing period.
• If you had sedation, do not drive or operate machinery for as long as the sedation team tells you. A UK national standard covers conscious sedation in dentistry. For adults, it says that every form of sedation other than inhalation sedation requires a responsible adult to take you home¹². It also says that if an escort cannot be assured, treatment under sedation must not be provided. If you are travelling alone, raise this before you book. The discharge rules for your method are explained in advance. The details are on the conscious sedation page.

Flying

A 2023 narrative review suggests waiting at least 72 hours¹¹ after an implant is placed before flying. After a sinus lift it suggests at least two, and ideally six, weeks. These intervals assume no pain, swelling or bleeding at the treated site. The authors say the research is limited and comes mostly from military aviation. Treat these intervals as a starting point for a conversation with the dentist who treated you, not as clearance. For a graft elsewhere in the jaw, ask the dentist who will treat you how long to wait before flying. Your written plan proposes flight dates on this basis; confirm them with that dentist after the treatment.

Later reviews

Follow-up after an implant is different from a general dental check-up. The 2017 consensus report asks for an X-ray and pocket measurements to be taken as a baseline¹³ when the crown or bridge is completed. Later changes are judged more reliably against that record. The UK's NICE guideline on dental recall asks for the review interval to be set for each patient¹⁴. For routine check-ups the shortest interval is three months; visits to manage a problem or ongoing treatment can be sooner. That guideline covers check-ups in general, not implants; a ready-made interval is not enough for a patient with implants. The European Federation of Periodontology guideline calls for a structured supportive care programme¹⁵ once implants are in use. Much of that care will be with a dentist near your home. Take your baseline X-ray and measurements home with you, and agree before you travel who will see you for reviews.

A graft does not lengthen treatment by the same amount for every patient. There are two main routes. Small grafts done in the same session as the implant often add no separate waiting period; treatment moves on with the implant's own healing time. In a staged graft, the graft comes first and the bone is left to form; the implant is placed later. This route adds a separate waiting period. For sinus floor augmentation, no significant difference⁹ in implant loss was found between these two routes. That does not show the two routes are equivalent for every patient. How much longer it takes depends on the size of the defect, the method chosen and how you heal. The time expected for you is given in your written plan.

What it means for your trips

If you travel for treatment, a staged graft means more trips than an implant alone. The graft is placed first. The implant follows once the bone has formed, which takes months, and the crown or bridge follows once the implant has healed. A small graft done in the same session as the implant often adds no separate trip. Your plan states how many trips you need, what is done on each and when you can fly. Have it in writing before you book travel.

After a sinus lift, the wait suggested before flying is at least two, and ideally six, weeks¹¹. Your stay in Turkey should allow for that wait. Your plan says how long you stay and when you come back for the next stage. Between the stages, a check with a dentist in your own country can help; see below.

We have found no study comparing the whole grafting process compressed into a short period with treatment spread over months. There are studies comparing early and later fitting of the teeth on implants. A Cochrane review of 26 randomised trials compared fitting the teeth straight away (immediate loading) with fitting them after healing (conventional loading). It found no evidence of a difference¹⁶ in implant loss. Follow-up ranged from 4 months to 1 year, and most of the trials were at high or unclear risk of bias. This finding does not show that a whole treatment with a graft can be fitted into a few days. The timing first has to meet clinical requirements: how the graft and the implant heal. Beyond that, judge it on practical grounds. How is healing checked? Who do you contact if something goes wrong? Which aftercare is included in the plan?

Between trips and after you go home

We try to arrange a check with a dentist in your own country between the stages, and write it into the plan. This may not be possible everywhere, because some dentists may not want to take over treatment in progress. So the plan also says where to turn if a problem arises in between. If a check at home is planned, ask for the records of the first stage before you fly home. That dentist needs them to see what was done. The Dutch dental association suggests discussing your plan with your own dentist¹⁷ before you go. It also suggests asking whether you can go to them if something goes wrong.

Before you fly home, ask for your record. It lists the graft material and membrane used, and the implant system if an implant was placed. Ask for your X-rays and scan too, and for your aftercare plan in writing. A dentist at home needs them to look after the area. In Turkey, the health tourism regulation entitles international patients to an itemised bill. On request, they also get free copies of the records of the materials used, the tests and the imaging¹⁸.

Problems after you return are usually first seen by a dentist where you live, and that dentist may not take over work done elsewhere. What a health service or an insurer covers after treatment abroad differs from country to country. Before you travel, ask the health service or your insurer in the country where you live. Ask what they would cover if the graft or the implant needs care at home.

Questions to ask before you commit

These are the questions we suggest you ask before treatment abroad. Ask us all of them, and ask for the answers in writing.

1. Who will carry out the surgery, and what are their qualifications?
2. How many times have you carried out this procedure, and what are your success, complication and infection rates?
3. Are you regulated by a professional body and registered with it?
4. If there is a complication, are the remake and correction terms in writing, and for how long do they apply?
5. What aftercare do you provide, and who can I contact after the treatment?
6. If there are complications, who pays for the further treatment, the extra flights and the hotel?
7. Do you have a complaints system, and can I see a copy?

We publish no graft or sinus-lift figures of our own yet. Ask us for them, and ask how complications were defined and over what period.

For a graft, also ask which graft material and membrane will be used, and where they come from. Ask too what happens if the graft does not take. The full list of questions to ask before treatment abroad is on our page about dental treatment abroad. Before treatment we give you, in writing, the route to follow if there is a complication and our remake terms. You can ask us for that document before you decide. You can take time to decide. You can say no, or ask to stop, at any stage, including after the examination. Ask before you travel what you would pay if the examination shows that the plan does not suit you. Having the treatment with a dentist where you live remains an option.

After surgery, contact your dentist if any of the following happens.

• Pain or swelling that increases after the third day, or bleeding that does not stop
• A high temperature, feeling unwell, or a bad smell and pus from the area
• Stitches opening, or the graft or membrane becoming visible through the gum
• Hard particles coming out continuously and in large amounts
• Discharge from the nose, a blocked nose or sinus pain on the treated side
• Liquid coming out of your nose when you drink, or air passing between your mouth and nose
• Numbness of the lip or chin that lasts beyond the expected duration of the anaesthetic

Before you fly home. Have the area checked before your flight, and take written instructions for your stitches, your medicines and your reviews. If any of these signs starts while you are still in Turkey, tell us before you travel.

Once you are home. Contact us through the route written in your plan. If pain or swelling keeps increasing, numbness persists, or there is discharge from the nose, also see a dentist locally without waiting for our reply. If your plan names a dentist at home, contact them as well.

Emergencies. Difficulty breathing or swallowing, rapidly spreading swelling of the face or neck, or swelling around the eye are serious signs. If you have any of them, do not wait for the clinic's reply. Go to the nearest emergency department or call the emergency number where you are (112 if you are in Turkey).

This page does not quote fees. The main factors in a plan are these:

• The size and position of the defect
• The method chosen
• The type and amount of graft material
• Whether a membrane is used
• Whether a block of your own bone is taken
• Sedation
• The number of trips and the review programme

The plan also states what will be done if the graft does not take. Ask in writing what your plan includes, and who pays for further treatment and extra travel if there is a complication. The Dutch dental association advises counting all the costs, travel and accommodation included¹⁷.