Bone Grafting and Sinus Lift: When Is It Necessary Before Implant Placement?

Dental implantation requires a sufficient volume of jawbone to securely fix the implant. Unfortunately, many patients have insufficient bone for implantation due to natural bone atrophy after tooth loss, periodontitis, or other causes. In such cases, procedures like bone grafting and sinus lifting are used to restore bone volume and create a strong foundation for implants. Below we’ll explore when bone grafting is necessary, the modern methods used in implantology, the difference between open and closed sinus lift techniques, what to expect during recovery, and which advanced technologies help accelerate implant healing.

Why might there be not enough bone for implantation?

After a tooth is extracted or lost, the jawbone gradually begins to shrink (atrophy). The lack of load on the bone (usually provided by the tooth root through its ligaments) leads to irreversible resorption — the bone’s volume and density decrease. As a result, just a few months or years after tooth loss, the socket area may have insufficient bone tissue for successful implant placement. For example, a standard implant typically requires at least around 10 mm of bone height and adequate width. If the bone is too thin or too short, the implant won’t have proper support and may fail to integrate.

Causes of bone loss:

• Prolonged absence of a tooth. The most common cause of bone atrophy is tooth extraction — without the root to stimulate the bone, rapid resorption occurs. The longer the area remains without a tooth, the more pronounced the atrophy becomes.
• Periodontal diseases. Chronic periodontitis (inflammation of the gums and bone surrounding the tooth) can lead to the loss of bone support. If a tooth falls out or is extracted due to periodontitis, the bone volume has already been reduced by the disease.
• Trauma or cysts. Traumatic tooth extraction, cysts, tumors, or other jaw lesions can also cause bone defects.
• Anatomical features. In the upper jaw, an additional factor is the proximity of the maxillary sinuses. After the loss of upper molars, the sinus can “expand” downward — the bone partition between the jaw and sinus becomes thinner (a phenomenon known as sinus pneumatization). This is why the posterior upper jaw often has insufficient bone height for implants, requiring sinus floor elevation (sinus lift).

How common is the need for bone grafting? According to studies, 25–50% of dental implant cases require prior bone augmentation. In other words, roughly one in every three to five implant patients undergoes bone grafting. Without sufficient bone volume, the success rate of implantation drops significantly, as the implant may not properly integrate with the jawbone. Therefore, bone augmentation is a widely accepted procedure and often the only solution to restore lost bone support for implants.

Bone Grafting (Bone Augmentation): Restoring Support for the Implant

Bone grafting is a surgical procedure aimed at restoring or increasing the volume of jawbone tissue in cases where existing bone is insufficient for implant placement. The dentist surgically adds bone material to the desired area to create a strong foundation (bed) for the future implant. Essentially, it involves regenerating the jawbone at the site of the defect.

Modern implantology offers several bone augmentation techniques, chosen depending on the specific clinical case:

• Guided Bone Regeneration (GBR). This method combines bone grafts with a special barrier membrane. The membrane covers the defect area and isolates it from soft tissue, allowing only bone to regenerate in the space rather than connective tissue. Bone granules or blocks are placed into the defect, covered with the membrane, which is fixed in place, and the gum edges are tightly sutured. The membrane prevents soft tissue ingrowth into the grafted area and guides bone regeneration. After a few months, the graft partially resorbs and is replaced by new bone. GBR is a well-documented technique for restoring localized bone defects around implants. Success depends on key principles: tension-free wound closure, good blood supply, space maintenance for new bone, and stable immobilization of the graft and membrane. This method is commonly used when bone wall defects are found at the implant site (e.g., thin or missing bone after tooth extraction).
• Use of bone graft materials. Bone material can be sourced in several ways. Autografts are the patient’s own bone, usually taken from another site (chin, mandibular ramus, or even the iliac crest of the pelvis). Allografts are donor bone from another person (bone bank), processed for safety. Xenografts are animal-derived bone materials, such as bovine or porcine bone, cleaned of cells to leave only the mineral matrix. Synthetic materials (alloplasts) are artificially created bone substitutes (e.g., hydroxyapatite granules, β-TCP – beta-tricalcium phosphate, bioglass, etc.). The choice of material depends on the clinical case – the doctor will explain which options are best for you. Often, combinations are used – for example, mixing your own bone with donor or synthetic materials enhances the graft’s osteogenic potential and volume. All these materials serve as a scaffold (matrix) for new bone to grow; some also release factors that stimulate bone formation.
• Bone blocks and ridge splitting. If the jaw ridge is too narrow, expansion techniques are used. Ridge splitting involves making a longitudinal cut in the bone and separating its walls to create a gap where graft material is inserted. Alternatively, block grafts – small bone blocks (from your own or donor bone) – may be fixed to the jaw using screws at the defect site to restore ridge shape. Over time, the block integrates with blood vessels and becomes part of your own bone.
• Growth factor additives. Modern research shows that using special additives – such as growth factor concentrate from the patient’s own blood (e.g., PRF – platelet-rich fibrin) or recombinant proteins (e.g., BMP-2 – bone morphogenetic protein) – can improve the outcome of bone grafting. The addition of bone substitutes and growth factors strengthens the bone and provides better regeneration results, stimulating faster and more predictable bone formation.

How is bone grafting performed? Depending on the volume of augmentation, the procedure can be carried out under local anesthesia (numbing the area of intervention) or under sedation. The dentist lifts the gum tissue to expose the jawbone and places the graft material into the defect area. If a membrane is used (GBR), it is fixed over the graft for stability. The gums are then sutured. The procedure usually takes from 30 minutes to 1–2 hours depending on complexity. After the surgery, slight swelling, discomfort, or pain may occur, which is managed with painkillers. Stitches either dissolve on their own or are removed after approximately 7–14 days.

How long does bone healing take? After bone grafting, time is needed for the transplanted material to integrate with your native bone and form a full-fledged bone structure. This usually takes several months – from 4 to 6–9 months, depending on the extent of the procedure and individual factors. During this time, osteoblasts (bone-forming cells) gradually grow into the graft and deposit new bone matrix. In cases of minor defects, a small bone graft may be performed simultaneously with implant placement, if the existing bone is generally sufficient – the implant is placed and a small amount of bone material is packed around it to ensure proper coverage of the metal screw. However, in cases of significant bone deficiency, augmentation is usually done first, then allowed to fully heal, and only afterward is the implant placed.

Note: During the healing phase, it is crucial to follow all doctor’s recommendations. Oral hygiene must be carefully maintained, but gently, to avoid trauma to the graft site. Antibiotics may be prescribed to prevent infection. The patient should avoid heavy physical exertion during the first days after surgery and refrain from smoking (as it impairs blood supply and hinders bone regeneration). If pain, swelling, or other complications occur, contact your dentist.

Sinus Lift: What It Is and When It’s Used

Sinus lift (elevation of the maxillary sinus floor, sinus lift, sinus augmentation) is a specific type of bone grafting procedure performed in the upper jaw beneath the maxillary sinus. The maxillary sinuses are air-filled cavities (sinuses) located within the body of the upper jaw, to the sides of the nose, above the roots of the upper molars. When these teeth are missing, the sinus gradually expands downward, and the alveolar bone becomes thinner. As a result, the height of bone between the sinus cavity and the oral cavity can be very limited (less than a few millimeters). A standard-length implant physically cannot fit into such a shallow bone or may perforate the sinus floor. This is when a sinus lift is necessary — a procedure to build up bone beneath the maxillary sinus floor.

When is a sinus lift needed? Main indications include:

• Missing one or more upper molars/premolars for an extended period, leading to bone atrophy and downward expansion of the sinus floor.
• Congenitally large maxillary sinuses that anatomically result in thin bone in the upper posterior jaw region.
• Consequences of periodontitis in the upper teeth, trauma, or surgeries that reduced bone height in this area.
• The desire to place implants in the upper lateral jaw where bone height is less than ~5 mm. Typically, if there is at least 8–10 mm of bone between the ridge and the sinus floor, implantation can proceed without sinus lift. With heights around ~5–7 mm, minimally invasive closed sinus lift techniques may be possible (see below). If bone height is less than ~4–5 mm, a traditional (open) sinus lift is usually required.

The essence of the procedure: The surgeon carefully lifts the mucous membrane lining the sinus from the inside, and places bone graft material into the space created between the sinus floor and the jawbone. This effectively “raises” the floor of the sinus by placing bone material underneath. Over time, this material turns into new bone, increasing the height of the alveolar ridge to allow for the placement of a properly sized implant.

Types of Sinus Lift: Open and Closed

There are two main techniques for performing a sinus lift:

• Open (lateral) sinus lift. This is a more invasive method used when the bone is very thin (≤4 mm). The surgeon makes an incision in the gums on the cheek side in the area of missing teeth, lifts the soft tissue, and exposes the lateral wall of the upper jaw — the bone wall separating the sinus. A small round-shaped “window” is drilled into this bone wall (about 1 cm in diameter), and the bone plate is partially cut and bent inward like a flap. Through the opening, instruments are carefully inserted under the sinus membrane, lifting it from the sinus floor to create a cavity. This space is then filled with prepared bone graft material (autogenous, donor, xenograft, synthetic, or a combination). Once filled, the bone plate is returned to cover the lateral window, and sutures are applied to the gums. Sometimes membranes are used to close the window. The advantage of the open method is that the surgeon can directly visualize the sinus floor and membrane and evenly fill the space with graft material — this method is suitable even when there is virtually no bone. Disadvantages include greater surgical trauma (multiple incisions, bone drilling), and therefore potentially more swelling, discomfort, and a longer healing period. After open sinus lift, a healing period of 4–6 to 12 months is usually required for osseointegration of the graft before implant placement, although in some cases with minor sinus elevation, implants can be placed simultaneously at the surgeon’s discretion.
• Closed (transalveolar or internal) sinus lift. This less invasive technique is used for cases of moderate bone atrophy, where the remaining bone under the sinus is ~5 mm or more. A key feature is that no lateral bone window is created; access is gained through the implant site. The dentist drills a standard implant hole (about 4 mm in diameter) in the upper jaw but stops short, leaving a 1–2 mm layer of bone before reaching the sinus. Using special thin instruments (osteotomes) or hydraulic pressure, the surgeon gently lifts the sinus floor along with the membrane. The newly formed space is filled with bone granules through the same opening. In many cases, the implant can be placed immediately if enough lift is achieved. Thus, closed sinus lift is often combined with immediate implantation, reducing overall treatment time. Advantages include lower surgical trauma (no wide gum incision, fewer stitches), shorter procedure time, and an easier postoperative period. Disadvantages: it requires sufficient initial bone height (~5 mm), as the technique is not feasible with very thin bone. Also, the surgeon operates “blindly” without direct visual control, requiring high skill and experience. When performed correctly, the closed sinus lift is a very effective and safe technique.

Recovery after sinus lift. Both methods are usually well tolerated by patients. The procedure is performed on an outpatient basis under local anesthesia, with optional sedation to reduce anxiety. Pain is usually minimal — many patients manage with standard painkillers (ibuprofen, acetaminophen). In the first 1–2 days, moderate swelling of the cheek or lips and minor spotting from the nose or mouth may occur — this is normal. The doctor will provide detailed aftercare instructions. Typically recommended:

• Avoid forceful nose blowing and sneezing with a closed mouth during the first 1–2 weeks (to avoid displacing the graft or injuring the sinus). If you need to sneeze, do so with your mouth open.
• Sleep with your head elevated on a high pillow for the first few nights to reduce swelling.
• Apply cold compresses to the cheek (10–15 min intervals) on the first day to minimize swelling.
• Avoid hot food and drinks on the day of surgery; afterward, stick to soft, cool, or room-temperature foods for a few days. Avoid carbonated beverages and acidic juices that could irritate the mucosa.
• Do not smoke or consume alcohol for at least 1–2 weeks, as these slow healing.
• Take prescribed medications: antibiotics to prevent infection, nasal sprays or saline rinses, and decongestants may be recommended. Use painkillers as needed.
• Avoid intense physical exertion for a few days, as it may increase bleeding.
• Attend your follow-up visit in about a week (or as instructed) — the doctor will check healing and remove stitches if needed.

Complete healing and integration of the bone graft after a sinus lift usually takes around 6 months (depending on volume — sometimes up to 9–12 months). Only after this stage does the dentist proceed to gum shaping and prosthetic restoration on the implant. Although it takes time, sinus lifting significantly increases the chances of successful implantation in problematic areas, providing long-term support for implants for many years.

Possible risks and complications. The most common complication during a sinus lift is perforation (tear) of the sinus membrane during surgery. It occurs in about 10–20% of cases and may increase the risk of infection or graft failure. An experienced surgeon can usually repair a small tear using a membrane or special glue, but in some cases, the procedure must be postponed to allow healing. Other possible complications include sinusitis (inflammation of the sinus), accidental displacement of bone granules or the implant into the sinus cavity, bleeding, or — rarely — temporary dizziness (due to proximity to the inner ear). Fortunately, with proper technique and post-op care, serious complications are rare, and over 90% of sinus lifts are successful.

Modern Technologies That Accelerate Implant Healing

Implantology is rapidly advancing, and today patients benefit from innovations that make treatment more predictable and faster. Here are several modern technologies that help shorten healing time for bone and implants:

• 3D Diagnostics and Digital Planning. Cone beam computed tomography (CBCT) and dedicated planning software allow the surgeon to assess jaw anatomy in fine detail before surgery. This enables optimal implant positioning, avoids risky zones (like sinuses or nerves), and identifies the need for bone grafting early on. Digital planning ensures maximum precision, reducing surgery time, trauma, and even promoting faster healing. For example, surgical guides created with 3D printing allow the implant to be placed exactly as planned on the first try, minimizing guesswork and incisions — improving predictability and outcomes.
• Advanced Implant Surfaces (SLA/SLActive). An implant’s surface refers to its microscopic texture. Traditionally smooth implants integrate slower than roughened ones. The Swiss company Straumann introduced SLA surface in the 1990s — sand-blasted with large particles + acid-etched — creating macro-roughness for better bone bonding. This halved healing time from ~12 to ~6–8 weeks. The next-gen SLActive surface (SLA active) is hydrophilic, stored in isotonic solution to retain blood-wettable properties, promoting even faster bone integration. Under ideal conditions, implants can reach sufficient stability in 3–4 weeks, allowing earlier prosthetic restoration. Other manufacturers also offer nano-textured, hydrophilic, or bioactive surfaces — all aiming to speed up osseointegration.
• High-Quality Implants and Materials. Modern implants are made from enhanced materials like Roxolid (developed by Straumann) — a titanium-zirconium alloy with superior strength. This allows thinner implants without compromising durability. For patients with narrow jaw ridges, slimmer but stronger implants may eliminate the need for bulky bone grafts. Likewise, short implants (e.g., 6 mm long) can be placed near sinuses or nerves where traditional implants would require sinus lifting or grafting. Long-term studies confirm the success of short implants and angled implants (like in the All-on-4 system) as alternatives to sinus lifts in select cases — making treatment more tailored and less invasive.
• Immediate Loading (Immediate Load). When strict criteria are met, a temporary crown can now be placed on the implant the same day it is inserted (“teeth in a day” concept). This is possible when the implant achieves high primary stability and sufficient bone volume is present. Modern implants with improved thread designs, stronger materials, and active surfaces make immediate loading more feasible. For the patient, this means avoiding the edentulous stage and restoring aesthetics and function faster. Still, the decision for immediate loading is made cautiously and individually to avoid compromising osseointegration.

In conclusion: Bone grafting and sinus lifting are routine and safe procedures in modern dentistry that make implantation possible even for patients with “not enough bone for an implant”. They restore natural jaw volume, enhance facial aesthetics, and give implants a solid foundation for many years. When planning dental implants, be sure to consult an experienced oral surgeon or periodontist. The specialist will assess your individual case using 3D imaging, explain whether bone augmentation or sinus lift is needed, and guide you through the treatment stages. Thanks to modern methods and technology, bone augmentation is highly predictable, and implant success rates exceed 95%, giving you a healthy and beautiful smile for years to come.