Oral and Maxillofacial Surgery

A tooth that cannot be kept

A tooth may need to come out when it is too broken down to repair, or when gum disease or infection has destroyed its support. If a filling, a crown, root canal treatment or gum treatment could keep it, those are discussed first. An extraction cannot be undone. In a simple extraction, the tooth is loosened with an instrument called an elevator and removed with forceps¹. In a surgical extraction, a small cut in the gum, removing some bone or cutting the tooth into pieces may be needed¹. Whether yours will be simple or surgical is sometimes clear only after the examination and X-rays. See tooth extraction.

A wisdom tooth that hurts or keeps getting inflamed

A wisdom tooth that is not painful and shows no disease is usually left in place and watched at check-ups². An impacted wisdom tooth cannot come through fully into its normal place. For impacted wisdom teeth without disease, a Cochrane review found insufficient evidence³ to decide whether removal or keeping them is better. Removal is discussed when there is disease, such as decay that cannot be repaired, infection, a cyst or gum inflammation that keeps coming back. Removing an impacted tooth is a surgical extraction. Dry socket is a painful condition in which the protective blood clot is lost from the socket. It is more common after the surgical removal of wisdom teeth than after routine extractions⁴. Less often, removing a lower wisdom tooth leaves the lower lip or chin numb⁵, because its roots can lie close to a nerve. This usually gets better but can take a few weeks or months²; rarely, it does not go away⁵. See wisdom tooth removal.

A missing tooth: implant surgery

A dental implant is an artificial root, usually a titanium screw, placed in the jawbone where a tooth is missing. Once it has fused with the bone, a crown or bridge is fixed on top. Placing it is surgery, and there is a healing period before the final tooth. Untreated gum disease is dealt with before an implant is placed. Afterwards, an implant needs cleaning and regular check-ups, because inflammation around it can lead to bone loss and to losing the implant. An implant is not the only way to replace a tooth: a bridge, a removable denture or leaving the gap are options too. See dental implants, which explains the risks and the maintenance.

Not enough bone for an implant

A bone graft builds up jaw bone where there is too little to hold an implant. In a sinus lift, the thin lining of the sinus in the back of the upper jaw is gently raised. Graft material is usually placed beneath it, to gain bone height for an implant. Neither replaces a tooth; both are extra surgical steps that make an implant possible. Not every patient needs one, and a graft is not the only route. For a shrunken (resorbed) lower jaw, a Cochrane review found short implants appear to be a better option⁶ than building the bone up in height. The same review found that complications were common, especially when bone was built up in height⁶. The review rests on few trials with few patients. See bone grafting and sinus lift.

Fear of treatment, or a long procedure

Most oral surgery is done under local anaesthetic. If you are very anxious, have a strong gag reflex or face a long procedure, conscious sedation may be discussed. It lowers anxiety, but you are not put to sleep: verbal contact with you is kept throughout the procedure⁷. A local anaesthetic is still given to numb the area. A general anaesthetic is a separate decision, with its own team and an approved setting. The conscious sedation page explains who it is not suitable for, its risks and the escort rule.

An extraction, a bone graft and an implant are often steps of one plan. The usual order is below; not every plan has every step.

1. Can the tooth be kept? A filling, a crown, root canal treatment or gum treatment is considered before an extraction.
2. The extraction. Decide before it how the gap will be filled. The options are an implant, a bridge, a removable denture or, for some gaps, nothing.
3. A graft, if the bone is not enough. In a staged graft, the graft comes first, and the implant follows once new bone has formed, which takes months. In some cases a small graft is placed in the same session as the implant instead.
4. The implant, at once or after healing. Sometimes the implant is placed in the same session as the extraction. In a 2017 review, 95.2 per cent of implants placed straight into the extraction socket survived, against 98.4 per cent in healed bone⁸. These figures are counted per implant and come from published studies, not from our own records. The difference was statistically significant, and the authors ask for caution with same-session placement.
5. The crown or bridge. It is fitted once the implant has fused with the bone.

The order decides how many appointments you need and how long the treatment takes. Ask for the whole sequence in writing before the first step.

Your dentist asks about your health and your medicines before any oral surgery. Tell your dentist if:

• You take a blood thinner, or an antiplatelet medicine such as aspirin. Do not stop or change it for dental treatment⁹ unless your dentist or doctor tells you to.
• You take, or have taken, a medicine for bone thinning (osteoporosis) or for cancer. Some of these medicines, such as bisphosphonates and denosumab, can rarely cause a healing problem of the jaw bone (osteonecrosis). A leaflet for people taking them for osteoporosis says that an extraction or an implant raises this risk, though it stays low¹⁰. It also advises them to keep taking the medicine. People taking them for cancer are at higher risk¹¹. During high-dose cancer treatment with these medicines, implant surgery is usually avoided; taking them for osteoporosis does not on its own rule implants out¹¹. Any change to the medicine is decided by the doctor who prescribes it.
• You have had radiotherapy to the head or neck.
• You have a heart condition, or your heart doctor has said you may need antibiotics before dental procedures.
• You have diabetes.
• You are pregnant, or might be.
• You smoke. Smoking is linked to dry socket after an extraction¹² and to losing implants¹³.

Also mention any other medical condition and any allergies, and bring a list of every medicine you take, with the doses. Implants and grafts are planned with a 3D scan, which shows the bone, the sinus and the nerve canal. For a wisdom tooth, a 3D scan may be requested if needed. An assessment based on photographs, or on an X-ray you send us, is preliminary, not final.

Turkish law authorises every dentist to diagnose and treat the teeth, the gums and the mouth and jaw tissues directly connected to them¹⁴. Turkish rules add further requirements for some procedures and settings¹⁴.

Oral and maxillofacial surgery (in Turkish, ağız, diş ve çene cerrahisi) is one of the dental specialties set by law in Turkey¹⁴. It has its own training. The rules say that only a dentist with a certificate in that specialty, registered by the Ministry of Health¹⁵, may use its title. Turkish law also lists surgery of the mouth, face and jaws (ağız, yüz ve çene cerrahisi) as a separate specialty of medicine¹⁴.

On this page, “your dentist” means the dentist who examines and treats you. Before you agree to surgery, ask who will carry it out, what their title is and how often they do the procedure. If you ask, you have the right to be told who is treating you, and their role and title¹⁶. Ask for the answers in writing.

When care belongs somewhere else

A Turkish regulation covers private dental practices, polyclinics, centres and hospitals that provide oral and dental care. It says that these facilities may carry out no medical procedure other than oral and dental care¹⁷. If your problem needs care beyond the treatments on this page, your dentist will tell you if you need a referral.

Some of the treatments on this page can also need another setting. If bone for a graft has to be taken from outside the mouth, general anaesthesia and a hospital stay may be needed. You are told in advance if this applies to you. If a general anaesthetic is discussed for you, ask where it would be given and by whom.

Turkey's patient rights regulation says what you are told before treatment. It includes who will carry out the treatment, where and how, and how long it is expected to take¹⁶. It also includes the other options with their benefits and risks, the possible complications, and how to reach medical help when you need it¹⁶. Ask for your plan in writing as well. It should list the treatments, their order and the materials to be used, such as any graft material and membrane.

In private dental clinics, you are asked to sign a consent form for every treatment¹⁷. The form is signed in two copies, and one copy is given to you¹⁶. You can look at your records and get a copy¹⁶, including your X-rays and scans. Before you decide, you can also ask for another dentist's opinion¹⁶.

You can say no, or ask to stop, at any stage. The regulation gives you the right to refuse treatment or ask for it to be stopped¹⁶; the possible consequences are explained to you. Once a tooth has been extracted, that step cannot be undone.

Sedation and the escort rule

If sedation is suggested, ask what kind it is and why. A 2022 Turkish regulation on private dental facilities covers where sedation may be given. Under it, treatment under sedation or general anaesthesia may not be carried out in a single-dentist practice (muayenehane) or a polyclinic (poliklinik)¹⁷. Your written plan names the place where any sedation is given; ask who will give it.

A UK national standard for sedation in dentistry sets an escort rule. For adults, it requires an escort for every form of sedation other than inhalation sedation⁷. If an escort cannot be assured, it says, treatment under sedation must not be given. The same standard expects advice on eating and drinking beforehand, given verbally and in writing⁷. It also expects written and spoken aftercare instructions for you and your escort, and arrangements for advice out of hours⁷. Ask us before the day whether the method planned for you needs an escort, and plan who will take you home. If you have sedation, do not drive or operate machinery for as long as the sedation team tells you.

Questions to ask

1. Who will carry out my surgery, and what are their qualifications and title?
2. Is my extraction likely to be simple or surgical, and what changes if it is surgical?
3. Will I need a graft? If so, which material and membrane, and where do they come from?
4. Which anaesthetic or sedation is planned, who gives it and where, and do I need an escort?
5. How many appointments will I need, and how long is the healing between them?
6. If there are complications, who pays for further treatment?
7. What aftercare do you provide, and how do I reach the clinic, including out of hours?

After any of these treatments, contact your dentist without delay if you have:

• Bleeding that does not stop despite pressure
• Pain or swelling that increases after the third day, or that painkillers do not relieve
• Pain that starts 24 to 48 hours after an extraction, a socket that looks empty, and a bad taste or smell. These can be signs of dry socket; the Scottish guidance recommends getting urgent dental care¹⁸
• A high temperature, feeling unwell, a bad taste, or pus from the area
• Numbness of the lip, chin or tongue that lasts after the anaesthetic has worn off
• If you take a medicine for bone thinning or cancer: unexpected pain, tingling, numbness or swelling at the treated site. Scottish dental guidance asks for these to be reported to your dentist¹¹
• After surgery in the upper jaw: discharge from the nose, a blocked nose, or liquid coming out of your nose when you drink

Emergencies. Swelling that makes it hard to breathe, speak or swallow, or that spreads to your eye or neck, needs urgent medical help¹⁹. Do not wait for a dental appointment or for the clinic's reply. Go to a hospital emergency department or call 112.

Each treatment page lists its own warning signs; the tooth extraction page also explains how to press on a socket that keeps bleeding.

This page carries no prices. A plan is prepared after an examination and X-rays, with a 3D scan for implants and grafts. The main factors that shape it are:

• Which treatments are needed, and how many teeth or implants
• Whether an extraction is simple or surgical
• Whether a graft or a sinus lift is needed, and the material used
• Imaging, anaesthesia and sedation
• Check-ups and stitch removal

Ask for your plan in writing, including what it covers. Also ask who pays for further treatment if there is a complication.