Dental Seminar Training Bone Leveling for Implants Testing Assessment Evaluation Services
Michigan Dental Seminars

Ara Nazarian, DDS
Advanced Bone Leveling
1857 East Big Beaver Rd
Michigan Dental Center
Troy MI 48083
(248) 457-0500

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Bone Leveling for Implant Dentistry

Advanced CtScan Planning and Treatment Protocol

Two major patient population groups of denture wearers grapple with the disappearing bone issue.

Paper Thin Bony Ridge
One group is comprised of the patients who started wearing removable prosthetics at a young age (perhaps due more to economic concerns).

The 2nd group represents younger senior citizens who were not as concerned about the long term effects of denture use due to life expectancy assumptions.

Much of that has changed. Life expectancy plays an important role in the types of treatment options patients should be offered when planning for teeth replacement.

Dentures No Longer An Option

More and more middle aged and senior citizens are being told that their bone loss problems prevent the continued use of dentures.

Ctscan Planning Software Guided Implants
Precision CtScan Treatment Planning
The patient pictured in the adjacent sequence of treatment photos is in her 50's and has worn dentures for 25 years. Her mandibular bony ridge no longer supports normal dental function.

Bone Grafting is the Only Solution

She had consulted with other dentists, prosthodontists, oral surgeons and periodontists learning that bone block grafting was the best and perhaps only treatment option, at a cost of approximately $45K - $50K.

Although block grafts (and other non-block grafts) represent the accepted treatment standard for fortifying or augmenting bone tissue.... there is another method for creating a foundation of D-1 class of bone that many dentists may not be completely aware of yet is taught in some of today's popular post graduate training programs.

Increasing Bone Density by Removing Unstable Bone

Ctscan Planning Software Guided Implants
Bone Leveling Guide Derived from Ctscan
This patient was seeking treatment that could create a ridge of bone of suitable quality that would support a small number of dental implants that would anchor a cantilvered porcelain fixed bridge.... all without breaking the bank and extensive, invasive bone grafting surgeries.

A Ctscan revealed that with selective bone leveling, the anterior region of the bony ridge could be modified to readily support a configuration of 5 implants (Branemark A-E positioning).

The scan presented in the 2nd photo shows the existing tissue level and where the bony ridge could be reduced to for providing a D-1 class of bone (see areas marked in green).

Implant Placement Guide
Integrated Implant Placement Guide
Since the patient has a very servicable upper denture, the stability concerns of having a cantilevered bridge became manageable.

Case acceptance was practically immediate. No intensive and extensive bone graft surgeries, drastically shortened treatment time and a new porcelain bridge... all at a cost that was MORE than 50% less than what the patient had been quoted by all other dentists and specialists.

Bone Leveling: Different for Implants

For denture prosthetics, the more uniform the height of the bony ridge, the more stable the denture will be. Many dentists and oral surgeons can trim bone height with free-hand movements of a motorized burr.

Guide for Bone Leveling
Surgical Guide Prevents Excessive Removal
Implant dentistry surgery, however, can require more precision that may be needed to overcome tissue degradation due to disease or to gain the best advantage possible of creating the most homogenous level of bone.

This technical concern, while problematic in times past, is now easily managed by the use of Ctscans. A well defined scan will readily reveal the healthiest segments of the bony ridge.

This assists the implantologist in developing the most stable configuration of implants possible and, as demonstrated in this case, define the amount of and location of leveling to create a uniform modified ridge.

Bone Removal Done
Bone Leveling Completed

Healthy Precision

The adjacent photo provides an excellent visual reference to how a bone leveling guide can establish an optimal level of bone for precision placements and long term endurance. Implants are selected on the basis width and height afforded by the revised ridge.

The surgical outcome will match the "planned outcome" that was derived during the study of the original scans. Errors commonly due to free-hand dentistry are eliminated.

Attaching the Implant Guide

The secondary guide is placed on top of the leveling guide and secured with the stabilizing pins.

Implant Surgery Guide
Implant Surgery Guide in Place
A series of graduated drill bits are used to sequentially prepare each implant site that eliminates problems with overheating of bone.

Metal shims are used as needed to assure proper centering within in implant site. This attention to detail eliminates failures due to "drift" of implant alignment.

Once completed, alignment pins are immediately inserted to confirm the degree of alignment required for accommodating a conventional or cantilevered bridge design.

Verify Alignment
Implant Alignment Check
Notice how, in the adjacent picture, how all implants are aligned perfectly, matching precisely the planned outcome developed with the 3D planning software.

No unintended implant surgery surprises here. Testimony to the superiority of virtual planning and the use of implant surgery guides.

Final Surgical Implant Placements

With confirmation of alignment now completed the selected implants are sequentially placed.

Placement and Depth Check
Xray Confirmation of Placement and Depth
A panorex is taken, confirming continued alignment and accurate implant depth that takes the best advantage possible of bone integrity.

Grafting products are used during the final suturing of the perio flap as necessary to assure the growth of ample, plump gum tissues througout the modified ridge and at each implant site.


Several weeks of healing (9 to 12) are provided to assure that the implants fully integrate with the revised ridge. The use of an RF instrument (e.g. Ostell Mentor or Ostell ISQ) is one of the most efficent and least invasive means of testing how well an implant has become osseointegrated.

Successful Implantology
Implant Healing Caps in Place
The adjacent photo reflects a fully healed mandible with sutures removed and an appropriate amount of gingiva trimmed at each healing cap.

Cementable abutments are placed and sealed with a resin product to protect abutment screws and to prevent bacteria accumulation.

In this picture a mirrored view reveals the symmetry of implant placements that provides the greatest stability possible for the patient's new bridge. The distribution of biting forces is idealized.
Top View - Implant Abutments

Acrylic Temporaries

Temporary bridgework is initally placed for a period of several days to a few weeks that provides ample time to assess and adjust overall bite dynamics needed for normal tmj function. Cosmetic and smile values are monitored by the patient.

Depending upon the "smile behaviors" of the patient, gingival tinting may be used to create an aesthetic result that best matches gum tissue characteristics along the arch.

Top View
Top View of New Fixed Bridge

Final Porcelain

Once all functional and cosmetic adjustments have been completed with the temporary prosthetic, the final restorative product is fabricated.

The full complement of 12 teeth with only 6 implants was achievable and "doable" because posterior biting pressures that would normally a cantilevered bridge have been controlled (effectively eliminated) by the patient's desire to use a removable denture on the upper jaw.

Frontal View
Mandibular Reconstruction Completed
The final outcome reflects a treatment that, while incorporating a lowering of the bony ridge, created little to no observable effect upon the vertical sizing of the prosthetic teeth.

Treatment options that theoretically might have included consideration of ridge splitting or block grafting were avoided. The risks associated with ridge splitting of paper thin bone or the osseointegrative risks associated with block grafts would likely have been enormous.

Virtual Dentistry

The advent of cone beam ctscans and 3D treatment planning software has not only improved "yesterday's" dentistry ..... it is responsible now for the development of treatment plans that would not otherwise be available today.

Time honored concepts of trial and error and "wait and see" dentistry is rapidly becoming an historical event within the dental profession. More importantly, virtual planning is within the reach of nearly any dentist or specialist.

High Tech 3D dentistry does not automatically determine that treatment costs will be higher. As in this case, it was used to create a mandibular reconstruction treatment plan that cut costs by 50% and made it immediately affordable for the patient.

The goal of "acquiring" servicable D-1 bone for this patient could not have been achieved as easily as this report outlines, without the use of 3D technologies and CAD/CAM products.


Dentists wanting to know more about how to affordably incorporate 3D dentistry and complex bone modification that does not require an outside specialist are invited to contact Dr. Nazarian directly via our Contact Form.

Michigan Dental Seminars
Ara Nazarian, DDS Seminar Leader
1857 East Big Beaver Road
Troy MI 48083
(248) 457-0500 - Fax: (248) 457-0501

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