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 and there is no bone left 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 published studies of implant loss, not from our own records. They show an association, not proven cause and effect. We have found no figure that measures graft success directly.

• Smoking. A 2020 review looked at people smoking more than 20 cigarettes a day. Their implant loss was about 2.5 times as likely per implant¹ as in non-smokers. Per patient it was about 4 times as likely. That review found no number of cigarettes a day that carried no extra risk. Smoking is also associated with poorer wound healing.
• Bone-strengthening medicines (bisphosphonates, denosumab). In a 21-study review, implant loss in people taking bisphosphonates was about 1.7 times more likely per implant². Osteonecrosis of the jaw, where an area of jaw bone dies and does not heal, 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). 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 (osteoradionecrosis). 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. That finding concerns the lower jaw. For the back of the upper jaw, we cite a patient leaflet on sinus lifts. Cambridge University Hospitals NHS Foundation Trust, in England, wrote it for its own patients. It says the risk of implant failure increases as the implant length decreases⁸. It calls the success rates good, but says complications are potentially more likely than with longer implants placed after a sinus lift. Several short implants might be an alternative, it adds. 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 the 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. An assessment made from photographs or X-rays you send is preliminary, not a treatment plan.

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 material⁹ and 99.6 per cent with a biomaterial, counted per implant. These are published figures, not our own. 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 difference¹⁰ 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.

Before you decide, you can also ask a dentist in the UK for an independent opinion. Ask whether you need a graft, what they think of the plan you are given, and whether to have the treatment in the UK instead.

This is the usual sequence at our clinic. Which method is chosen depends on the scan and the shape of the defect. The number of visits, the gaps between them and the waiting periods are given in your written plan; they vary from patient to patient. How the stages fit into visits to Antalya is explained in "Visits to Antalya, and the time between them" below. If you are considering sedation, see sedation and anaesthesia.

Risks

The figures in this section 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 cent¹¹. 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. A Cochrane review of 13 randomised trials states that complications are common, especially with vertical augmentation (building the bone up in height). 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 found no sourced figure for how often these happen.
• The nerve in the lower jaw. The nerve canal is close in the back of the lower jaw, so the lip and chin may feel numb for a while. Rarely, the numbness does not go away.
• 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 review suggests waiting at least two, and ideally six, weeks¹² after a sinus lift before flying. That assumes no pain, swelling or bleeding. This affects how long you stay in Turkey after the operation.

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 implant¹⁰. 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 come from published studies, not from our own records. They are outcomes observed in studies, not promises, and 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 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 the sinus area was treated, do not blow your nose. The UK hospital leaflet on sinus lifts advises not blowing your nose for two weeks⁸ after the operation. Follow your own written instructions for how long. The leaflet lists bony material that may have been dislodged after sneezing or blowing your nose⁸ as a reason to contact the surgeon. Ask whether your written instructions add other rules, for example on sneezing or drinking through a straw.
• 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. The UK national standard for conscious sedation in dentistry requires an escort for every form of sedation other than inhalation sedation in adults¹³. A responsible adult takes you back to where you are staying and stays with you as instructed. If an escort cannot be arranged, treatment under sedation is not carried out. Before you leave the clinic, you and your escort should have written aftercare instructions. You should also know how to reach the clinic, including out of hours.

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 baseline¹⁴ when the crown or bridge is completed. Later changes are judged more reliably against that record. The NICE guideline on dental recall asks for the review interval to be set for each patient¹⁵. For routine check-ups the shortest interval is three months. Visits to manage a problem or ongoing treatment can be sooner. That guideline is not specific to 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 programme¹⁶ once implants are in use. Much of that care will be with a dentist near your home in the UK. Take your baseline X-ray and measurements home with you, and agree before you travel who will see you for reviews.

After surgery, or at any time later, contact us if any of the following happens.

• Pain or swelling that increases after the third day, or bleeding that does not stop. After a sinus lift, the UK hospital leaflet gives swelling or pain that gets worse after two days⁸ as a reason to contact the surgeon
• 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 that does not settle
• 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 longer than you were told to expect

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. See a dentist near you as well if pain or swelling keeps increasing or bleeding does not stop. Do the same for signs of infection, lasting numbness or discharge from the nose. Do not wait for our reply. If your plan names a dentist in the UK, contact them as well. In England, if you have no dentist or cannot get an emergency appointment, the NHS says to call 111 or get help from 111 online¹⁷. They can tell you where to get help, and you may have to pay for the appointment. Elsewhere in the UK, check the local arrangements.

Emergencies. In the UK, call 999 or go to A&E¹⁷ if you have any of the signs below. Do not wait for our reply. In Turkey, call 112.

• It is hard to breathe, speak or swallow
• There is a lot of swelling in your mouth, or it is hard to open your mouth
• Your eye is swollen or painful, or your eyesight changes suddenly
• Your neck is swollen¹⁸

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 difference¹⁰ 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.

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 difference¹⁹ 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, the questions are practical. How is healing checked? Who do you contact if something goes wrong? Which aftercare does the plan include? Ask for the answers in writing before you book.

How many visits

Implant treatment usually needs at least two visits to Antalya, because a healing period separates the surgery from the final crown or bridge. A small graft done in the same session as the implant often adds no separate visit. A staged graft means more visits than an implant alone. The graft is placed first, the implant follows once the bone has formed, and the crown or bridge follows once the implant has healed. Your plan states how many visits you need, what is done on each, how many days each one takes and when you can fly. Have it in writing before you book travel.

The examination in Antalya may change the plan made from your X-rays. A graft may turn out to be unnecessary, or a larger one may be needed. Ask before you travel what you would pay in that case.

When you can fly

A 2023 review suggests waiting at least 72 hours¹² after an implant is placed before flying. After a sinus lift it suggests at least two, and ideally six, weeks. Both times assume there is no pain, swelling or bleeding where you were treated. The authors say the research is limited and comes mostly from military aviation. They call these intervals a starting point for the dentist's decision. Treat them as the start of a conversation with the dentist who treated you, not as clearance. If you are to have a sinus lift, ask before you book how long you will stay in Turkey afterwards. Ask too who decides when you can fly.

At home, between visits

New bone needs time to form before the implant is placed, and the implant needs time to heal before the crown or bridge. How long depends on the size of the defect, the method chosen and how you heal; you are told your own period after the examination. Do not shorten it to fit travel plans.

The NHS website for England advises you to discuss your plans with a GP²⁰ before making any final decisions about travel or medical arrangements. The GDC says it is always a good idea to speak to your own dentist²¹ before treatment abroad. They may be able to advise you from your dental history. Ask now whether they will see you between the visits and afterwards, and whether you can go to them if something goes wrong. If you do not have a regular dentist, find one, NHS or private, before you travel. A check with a dentist in the UK between the stages can be written into your plan. If so, ask for the records of the first visit before you fly home, so that dentist can see what was done. Some dentists may not want to take on treatment that is in progress. So the plan also says where to turn if a problem arises in between.

Once you are back in the UK, the first person to see a problem may be a dentist near you rather than us. Plan for that before you travel.

• Signs of infection or a sinus problem. The signs are listed under "When to contact a dentist" above. Contact us through the route in your plan, and see a dentist near you with your records.
• A graft that does not take. Part or all of the graft may be lost. Once the area has healed, the graft can be repeated, or the plan changed to an option that needs less bone. That may mean another visit to Antalya.
• An implant that fails. Further surgery, another graft or a different restoration may be needed, and that may also mean another visit.
• Who pays. The GDC suggests asking whether work is guaranteed and for how long; it does not set a minimum period itself. Our written remake terms state who pays for further treatment and travel (see "Is the work guaranteed?" below).
• Reviews. Reviews can be done in Antalya or, where your plan says so, with a dentist in the UK. Ask who will do yours and who pays for them.

What the NHS does and does not do

The NHS Business Services Authority publishes guidance for dentists in England and Wales. It says a patient treated abroad is dealt with like any patient previously treated by another provider. If an NHS practice accepts you, it provides the clinically necessary treatment its NHS contract covers, with your consent. But some entitlements do not apply where another provider did the original work. These are further treatment within two months, free repair or replacement, and a replacement appliance under Regulation 11²². That guidance does not say a graft or an implant will be repaired or redone on the NHS. It covers England and Wales. Scotland and Northern Ireland have their own NHS rules, which this page does not cover; ask the practice you plan to use. The NHS also states that it is not liable for negligence or failure of treatment²⁰ you receive abroad.

Travel insurance

The NHS warns that most travel insurance policies will not cover you for planned treatment abroad²⁰, so you may need specialist cover. Ask your insurer, in writing, before you book.

The UK General Dental Council lists thirteen questions²¹ to ask before dental treatment abroad, and the NHS has its own checklist. Below are the ones that matter most for a graft or a sinus lift, each with our answer. Where our answer is a commitment rather than something you can check today, it says so. Ask us the full list, and ask for the answers in writing.

Who will treat me, and how can I check their registration?

We name the dentist who will carry out the graft or sinus lift, in writing, before you commit. In Turkey a dentist in private practice must register with the provincial or regional dental chamber²³ within a month of starting. Without it, they cannot practise privately. The Turkish Dental Association's website offers a search of registered dentists by name and province²⁴. Ask us for the treating dentist's registration details. Registration in Turkey is separate from the UK register: the GDC states that only people registered with it can legally practise dentistry in the UK²⁵.

How often do you do this, and what are your complication rates?

The GDC suggests asking how many times the procedure has been carried out, and the success, complication and infection rates²¹. The figures on this page come from published reviews, not from our own patient records. We publish no graft or sinus-lift figures of our own yet, so ask us for them, how complications were defined and over what period.

Is the clinic licensed and regulated?

In Turkey a dental clinic cannot open without a licence or treat patients without an operating permit. It is inspected at least once a year²⁶. To treat international patients, a facility also needs an authorisation certificate from the Ministry of Health²⁷. The Ministry publishes a register of authorised facilities²⁸ that you can check yourself. We give you our authorisation details before you commit. A licence or authorisation is a legal minimum, not a statement about the result of your treatment. The GDC itself cannot guarantee that a regulator like it exists in another country²¹.

Will I get the plan in writing?

Yes. The GDC says you should be assessed by a qualified dentist before being given a treatment plan and cost estimate²¹. Your written plan states whether you need a graft or a sinus lift and why, the method, and the alternatives. It names the graft material and membrane and where they come from. It also states what the plan covers and does not cover, and how many visits are needed. A plan made from photographs or X-rays you send is preliminary. It is confirmed after the examination and 3D scan, and we tell you before anything in it changes. 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.

Is the work guaranteed?

The GDC suggests asking whether the work is guaranteed and for how long²¹. It also suggests asking whether further treatment is included if there are complications, and who pays for extra flights, hotel and remedial work²¹. Before you commit, we give you our complication route and remake terms in writing. They state what is covered, for how long and what is excluded. They also say what happens if the graft does not take or a sinus lift has to be stopped. They state what you must do to keep the cover, such as attending reviews, and who pays for further treatment and travel. Read that document before you decide, rather than relying on the word "guarantee" on any web page.

Is there insurance if something goes wrong?

The GDC list also asks about insurance²¹. In Turkey a facility treating international patients must take out complication insurance for surgical and interventional procedures carried out in an operating theatre²⁷. That does not by itself tell you whether your graft or sinus lift is covered, so ask which procedures in your plan fall under it. Ask us too, in writing, whether the clinic or the treating dentist holds insurance for complications or errors, and what it covers. Travel insurance is covered under "If the graft fails or a problem appears after you are home" above.

Who do I contact after treatment?

Your written plan names the contact route for questions and problems once you are home, and your review interval. For urgent symptoms, get emergency care where you are first (see "When to contact a dentist" above).

What records will I take home?

The NHS lists exchanging medical records and arranging aftercare back home²⁰ among the things to consider. In Turkey you are entitled to an itemised bill, and on request to free copies of the records of materials, tests and imaging²⁷. You may also examine your file and take a copy²⁹. Before you fly home, ask for your record in a form a UK dentist can use. It should list the graft material and membrane used, with their brand names and batch numbers, and the implant system if an implant was placed. It should also include your X-rays and scan, and the baseline measurements once the crown or bridge is fitted. A dentist in the UK needs it to look after the area.

What if I am unhappy, and where can I complain?

We give you our written complaints procedure before treatment. A complaint goes to the clinic first; private dental polyclinics, centres and hospitals in Turkey must have a patient rights unit²⁶. If the clinic does not resolve it, you can apply in writing to the provincial health directorate's Patient Rights Board²⁹. The Board decides within thirty days, but it does not assess allegations of medical error. The dental chamber can also open disciplinary proceedings²³ against a dentist. Do not expect the UK regulator to settle it. The GDC states that it cannot resolve complaints or help with refunds²⁵; its investigations are about whether dental professionals are fit to practise.

Will the team speak English?

The GDC suggests asking whether the team speaks your language and, if not, whether a translator is provided²¹. We confirm in writing, before you commit, who will explain the plan, the consent form and the aftercare instructions to you in English.

Warning signs, including for us

The NHS checklist names five signs to think twice about before booking. They are a hard sell, a lack of information, pressure to make a quick decision, no discussion of possible complications, and no mention of aftercare³⁰. Apply them to us too. If you feel pushed to decide quickly, wait.

No prices are shown on this page. 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 visits 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 included³¹. For you, that means your travel for every visit, and reviews with a dentist in the UK.