Surgical Dentistry in Astana: Extraction, Implantation, Bone Grafting

When a tooth is extracted without incising the gum

A simple extraction is performed when the crown is intact and the doctor can grasp it with forceps. The gum is not incised, and the periosteum is not detached. The tooth is loosened with side-to-side movements and then removed from the socket. This approach is suitable for single-rooted teeth and most multi-rooted teeth with straight roots, provided there is no inflammation in the surrounding tissues and no bone loss. The crown is secured with forceps or an elevator, and force is applied along the axis of the tooth. After removal, the socket is examined and sutured if necessary. The procedure is performed under local anesthesia. The patient remains in the chair, and hospitalization is not required. Healing follows the usual course: a blood clot covers the socket, and the tissues recover without additional manipulation. The doctor gives aftercare instructions and schedules a follow-up examination. If during the procedure it turns out that the root is curved or fractured, the approach is changed on the spot. The simple extraction then becomes a complex one. The patient is informed of this before the manipulation begins if the complexity is visible on the X-ray in advance.

Signs that classify a procedure as complex

How does the doctor choose the extraction approach?

The approach is determined by the X-ray and clinical picture. A panoramic radiograph or periapical X-ray shows the shape of the roots, their number, inclination, and the thickness of the surrounding bone. If the roots are straight and the crown is intact, a simple extraction is planned. When the X-ray reveals curvature, root fusion, or retention, the doctor prepares for a complex approach in advance. The final decision is also made during the procedure: bone density, tooth mobility, and tissue response are only visible during the work. The same tooth in two patients may be extracted differently. The patient's condition also matters: with a tendency to bleed or while taking blood-thinning medications, the approach is changed. The doctor assesses whether an incision is needed, whether the tooth will be sectioned, and whether socket suturing will be required. The patient is explained the plan before the manipulations begin. If during the work it turns out that the case is more complex than expected, the surgeon adjusts the course of the intervention. This is normal practice, not a planning error. The decision remains with the doctor.

What happens to the bone of the upper jaw

After the loss of chewing teeth, the bone tissue in this area decreases. The proximity of the maxillary sinus also plays a role: it pneumatizes, meaning the air cavity gradually expands downward. The sinus floor descends, and the layer of bone between the sinus and the oral cavity becomes thin. Sometimes its thickness is a couple of millimeters. The implant must sit in the bone and not perforate the sinus floor. If there is insufficient height, the implant either does not stabilize or presses against the mucosa. Then, before placement, a height reserve is created. The sinus mucosa is carefully elevated, and bone material is inserted under it. Over time, it is replaced by the patient's own tissue. How much exactly needs to be augmented is decided by the doctor based on the X-ray. In some cases, a closed approach through the socket is sufficient; in others, an open approach through the lateral wall is needed. This depends on the clinical picture, not on the patient's preference.

When sinus floor elevation is unavoidable

What examinations are performed before surgery

A computed tomography scan is required before the intervention. It shows the bone height, the thickness of the sinus walls, the condition of the mucosa, and the location of the septa. Based on the scan, the doctor chooses the approach: closed, through the socket of the extracted tooth, or open, through the lateral wall. Sometimes CT is not enough, and additional studies are prescribed. If there are signs of sinusitis, the inflammation is treated first; otherwise, it is too risky. The dentist also assesses the general condition: chronic diseases, medication use, allergies. Oral hygiene is evaluated separately. Plaque and gum inflammation are reasons to postpone surgery until sanitation. All this is not a formality. The preparation determines how the sinus mucosa will behave and whether the bone material will integrate. The final decision is made by the doctor after examination and X-rays.

Access to the sinus and scope of intervention

In which cases each option is chosen

The closed approach is used when the patient's own bone height is sufficient for the implant to be placed stably. The gum is not reflected; access is gained through the socket. The sinus membrane is lifted carefully, and the osteotomy is performed blindly, so the surgeon's visibility is limited. If the sinus wall is thin or there are septa, this route becomes risky. In that case, an open approach is planned: a window is created in the lateral wall, and the membrane is reflected under direct visual control. This allows more bone tissue to be added and enables work in complex anatomy. The open approach is often chosen for significant height deficiency, when the closed approach simply cannot provide the needed volume. Sometimes it is combined with bone grafting. The decision is made by the doctor based on imaging and the clinical picture, not on the patient's preference. The two approaches are not competitors but tools for different tasks. It also happens that one stage is performed first, and the implant is placed later, once the bone has matured.

What happens after surgery

After a closed procedure, swelling is usually moderate, and there are no incisions, so healing is calmer. The patient is advised not to blow their nose or sneeze with the mouth closed, not to fly in the first few days, and not to drink through a straw. These restrictions are temporary and depend on the clinical picture. After an open approach, swelling and discomfort are more pronounced: the mucosa was reflected and a window was created. A hematoma on the cheek and bloody nasal discharge may occur. Healing takes longer, and sometimes a second stage is required before implant placement. Follow-up examinations and imaging show how the mucosa is behaving and whether bone is forming. The duration of wearing temporary restorations and the timing of implant loading are determined by the doctor. If severe pain, fever, or nasal discharge occurs, you should contact the clinic rather than wait for it to resolve on its own. Scheduled visits are still necessary: they are how recovery progress is assessed.

Why bone shrinks after tooth loss

Bone tissue remodels throughout life. Its cells work in two directions: some build new tissue, others resorb old tissue. As long as the tooth transmits load through the ligament to the bone, the balance is maintained. After tooth loss, the signal disappears. Resorption begins to outweigh formation. In the first months, the process is faster, then it slows down but does not stop completely. After a year or two, the ridge height noticeably decreases, and the width narrows. A removable denture presses on the gum and underlying bone, adding to the problem. Inflammation around adjacent teeth also accelerates bone loss. If an implant is placed nearby, it takes on the load and slows bone loss in its area. Therefore, the interval between extraction and implantation matters, but the doctor decides based on the clinical picture. Sometimes waiting is not an option; sometimes it is reasonable to wait for soft tissue healing.

Methods of bone volume restoration

How bone sufficiency for an implant is assessed

Assessment begins with an oral examination. The doctor examines the gum, its thickness, ridge width, and the condition of adjacent teeth. Then imaging is needed. A panoramic X-ray gives an overall picture of the jaws, but it is not enough for planning. Computed tomography shows volume in three dimensions: height, width, and density. From the slices, the amount of bone around the future implant is calculated, and whether it will affect a nerve, sinus, or neighboring roots. Density also matters: in soft bone, primary stability is weaker, and the approach is changed. Occlusion and load distribution are assessed separately. Sometimes deficiency exists only in one area while there is enough bone nearby, and then a tilted or short implant is planned. If volume is insufficient, augmentation and its stages are discussed. The final decision is made by the doctor together with the patient, taking into account general health and willingness to undergo additional procedures.

How the protocol works and what it relies on

The protocol involves placing four supports in the jaw. Two are placed vertically in the anterior region, and two more are placed at an angle in the posterior regions. The angulation is needed to bypass anatomical obstacles: the maxillary sinuses above and the mandibular canal below. This allows avoiding additional bone grafting procedures in the posterior areas. The support is distributed so that the load falls on the anterior, denser areas. The restoration can be fixed or conditionally removable. In the first case, the bridge is secured with permanent screws; in the second, it is attached with locking attachments, and the patient removes it for hygiene. Intermediate options also exist. The final choice depends on the clinical picture: bone density, gum condition, bite, and the person's habits. Sometimes five or six supports are placed instead of four—these are different protocols and should not be confused with the classic one.

Situations in which All-on-4 is considered

Limitations and conditions of use

Not every jaw is suitable for the four-support scheme. The doctor assesses the volume and density of bone in the anterior region—that is where the main load will be. If there is also insufficient tissue there, the protocol may not be suitable. The condition of the gums matters: in case of active inflammation, treatment is carried out first, otherwise the implants risk failing to integrate. General diseases also play a role. Uncompensated diabetes, bleeding disorders, and certain endocrine conditions are reasons to discuss risks separately. Smoking slows healing, and this is also taken into account during planning. There are also anatomical limitations: the position of the mandibular canal, the size of the sinuses, and bite characteristics. Sometimes preliminary preparation is needed—for example, sinus lift or bone grafting. There are also cases where more supports or a different method are required. The doctor decides based on imaging and examination findings. There is no universal answer as to who is suitable for the protocol: each case is evaluated individually.

Healing stages and their approximate timelines

What affects the speed of recovery

When to see a doctor outside of the scheduled plan

If the pain intensifies instead of subsiding, or persists for more than a few days, this is a reason to come in for an examination. The same applies to swelling that increases rather than decreases, and to fever. Bad breath, pus, or bleeding that does not stop require a visit without waiting. Sometimes the clot does not form or is washed out, and the socket remains open—then the doctor decides whether it needs to be closed or treatment prescribed. You should not warm your cheek, pick at the socket, or rinse it vigorously on your own: this can dislodge the clot and trigger inflammation. If in any doubt, it is better to see a specialist: an examination will show whether healing is proceeding normally or help is needed.

The first 24 hours after surgery

Hygiene in the following days

You can brush your teeth after surgery, but the movements around the wound itself are different. In the first few days, use a soft brush near it, without pressure, and do not touch the wound at all — the clot and stitches need to be left undisturbed. Brush the other teeth as usual, twice a day: plaque and bacteria on neighboring teeth do not help the wound. Do not rinse vigorously — a strong stream washes away what is forming in the socket. If your doctor has prescribed rinses or mouth baths, hold the solution in your mouth gently and release it without force. When you can return to a regular brush and toothpaste depends on the clinical picture: with a simple extraction the timeline is one thing, after bone grafting or a sinus lift it is another, and your doctor decides at the follow-up visit. Do not use dental floss in the surgical area for now. An oral irrigator should also be postponed: a directed stream under pressure breaks up the clot. If you have stitches, do not pull on them with your tongue or try to check them with your finger. Being careful matters more than being thorough here.

What to avoid during healing

The doctor makes the decision based on the scans

A treatment plan isn't chosen based on an online description. The scan shows bone thickness, the position of the mandibular canal, the condition of the sinus, and the neighboring teeth. Based on this data, the dentist decides whether there is enough bone volume for the implant or whether bone grafting is needed first. Sometimes the scan reveals something you can't feel: a hidden cyst, a thin socket wall, or a nerve running close by. Then the plan changes. The patient may want one thing, but the anatomy dictates another. It makes sense to discuss the options after the diagnostic workup, not before. If the dentist suggests an option other than the one you expected, ask why. The answer should be based on the scan, not on generalities. A second opinion is also an option: it's standard practice, not a sign of distrust.

Recovery happens gradually

Tissues do not heal in a single day after surgery. First the swelling subsides, then the soft gum forms, and later the bone remodels. Each stage has its own sensations and its own restrictions. At some point you cannot chew on the side of the intervention, at another you cannot have hot foods, and at another you cannot fly. The timeline depends on the clinical picture: the extent of the intervention, bone density, age, and habits. Smoking slows healing, but exactly how much cannot be predicted. Painkillers are taken according to the regimen prescribed by the doctor, not on the advice of friends. If the pain intensifies instead of subsiding, that is a reason to call the clinic, not to wait. The same applies to fever and bleeding that does not stop.

Aftercare and follow-up visits

Hygiene after surgery differs from your usual routine. For the first few days, do not touch the surgical area with a toothbrush, but brush the other teeth as usual. Then add a soft brush, an oral irrigator used cautiously, and an alcohol-free mouthwash. The doctor shows you how to care for the sutures and when to have them removed. Follow-up visits are not just a formality: they check how the gum is healing, whether there is inflammation around the implant, and whether the temporary restoration fits properly. Missing a follow-up visit is a waste of time, not a saving. If you notice bad breath, tooth mobility, or swelling a week after surgery, book an appointment outside the regular schedule. X-rays during treatment stages are taken to see what the eye cannot. It is worth coming in for a check-up even if you feel well: some problems develop without pain.