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Bone Reduction Leveling For Dental Implants to Avoid a Bone Graft

Bone leveling is a procedure called “alveoloplasty.” Bone leveling is extremely beneficial in cases where a bone graft can be avoided altogether. Especially in the lower jaw when the bone atrophies, (melts away) what’s left of the bone is just a skinny spine knife edge type of ridge where the teeth used to be. That skinny knife edge ridge will not allow a normal size implant to fit inside of it.

stimulation of bone reduction leveling to take off the skinny part of the jawbone.  This is the jawbone in cross section.
stimulation of bone reduction leveling to take off the skinny part of the jawbone. This is the jawbone in cross section.

What’s interesting about our jawbone especially in the lower jaw and even in the upper jaw is it is shaped like a triangle if you look at it in cross section. The top of the bone is the apex of the triangle which is skinniest and the bottom of the bone is the base of the triangle which is the widest. So if your bone is really skinny at the tip and is wider at the base, a bone leveling alveoloplasty reduction procedure can take top of the triangle off leaving a wide base of bone to place the implants.  The procedure has minimal risks.

I do this very commonly when replacing implants in the lower jaw when all teeth are missing. This serves many purposes. One purpose for leveling bone is to avoid bone grafting. A second purpose would be to provide bone around the entire head platform of the implant. Finally, bone leveling for dental implants reduces cost to the patient and decreases the time until you get your final teeth… A win-win situation!

Bone reduction alveoloplasty example (1)
Before —note uneven bone that is higher in the front of the mouth where some broken roots remain
Bone reduction alveoloplasty example (2)
Before —note uneven bone that is higher in the front of the mouth where some broken roots remain
sample real case bone reduction for dental implants (1)
Before —note uneven bone that is higher in the front of the mouth where some broken roots remain
sample real case bone reduction for dental implants (2)
After –simultaneous extraction, bone leveling and placement of four dental implants….this is healing at one month
Bone reduction alveoloplasty example (3)
After -Bone reduction alveoloplasty example

Why don’t we just do this for all implants?

Why is this only limited to full arch replacement such as a Prettau dental implant bridge or when replacing large segments of teeth?

The reason is that it makes the teeth longer from the gum line to the top of the tooth. If you are missing all of your teeth bone leveling (as opposed to bone grafting ) can be extremely beneficial because it provides thickness to the overdenture or fixed dental implant bridge such as the Prettau.

Having significant thickness of your bridge will prevent problems that you may not think about such as breaking your bridge or breaking your implant overdenture. This happens so commonly when the depth of the implant is too shallow and a full arch zirconia, hybrid all on 4 bridge or overdenture case is made and the material was so thin that it just breaks in half or the teeth chip or fracture off.

Bone leveling reduction alveoloplasty can be very important for replacing all upper teeth also especially if you are missing gum tissue. Sometimes we have to use pink tissue ceramic colored porcelain to mimic lost gums. You never want this transition between the prosthetic pink gum and your natural gum to show when you smile. Although the pink gum tissue looks very natural, it does not look natural if you see the line between the two in full smile. So sometimes a bone leveling reduction alveoloplasty is done in order to hide the transition. I have been doing this procedure for at least 15 years as of 2015.

Other Benefits

Another other benefit is the bone shavings can be used to graft another area of the mouth that may need bone! This can be combined with L PRF/PRP (made from your own blood)  and other bone grafting materials to as your own bone and make a composite bone graft that is extremely successful.

Bone leveling is also important to make sure that the heads of all the implants are all relatively on the same plane. It is extremely common for the lower jaw to be missing more bone in the back and the bone to be sticking up in the front. This bone that is sticking up in the front is usually reduced for thickness purposes and to make sure the implants are at a good level with the rest of the bone and the other implants. Typically I do this procedure when I am placing anywhere between 3-10 implants in the jaw. It also allows for the gum to be closed very well and stitch in such a way that the gums almost always touch each other. This is called primary closure and leads to fast healing from surgery.

What is the disadvantage of this procedure?

If bone leveling reduction alveoloplasty is used in the wrong location, such as a single missing tooth, you will end up with a huge, open black triangles between your teeth. It is not meant to be used in cosmetic areas of the mouth such as upper front teeth. These areas are better served with bone grafting than bone reduction leveling. It is meant to treat long span missing teeth or when you are missing all teeth. Bone reduction alveoloplasty needs to be carefully planned from a full set of photographs and a 3-D scan. The point is to take away just enough bone but not too much.

Please feel free to comment and ask questions.  Please use the proper area of the blog to do so

36 thoughts on “Bone Reduction Leveling For Dental Implants to Avoid a Bone Graft

  1. Last month I had all of my upper teeth removed. They also did alveoplasty. I had stated I wanted implant dentures. I have always had a prominent upper jaw and a serious overbite. I was told that the mouth would have to heal from the extractions for 4 -6 mos before implants and sinus lift. Until then I have standard upper denture.

    They have taken so much bone that even with the dentures in, my face looks shrunken and much older. I know this will get worse each month that goes by. They are now making a new denture with a huge addition to hold out my upper lip. I had originally thought I would go with the 4 implant/removeable denture, but now feel I would like something that stays in. I am very much freaked out by that empty mouth. I went back to the dentist last week about this issue and told him I wanted to spend more for full implants, which he tried to steer me away from. I want full implants then am I left with this damaged face without the large amount of acrylic in a 4 implant denture? In addition, I had extensive surgery on my nose a few years ago for skin cancer, which I pointed out to him in advance. Now without the upper jaw supporting the face that side droops, especially when talking or when I’m tired.

    Is the dentist responsible for creating this mess? What can be done from here?

    I cannot afford going to CA. I am in FL. If I give up any hope of owning a home, I can spend $30K – $40K.

    1. I have a post specific to lip and facial support both for regular implants and for zygomatic implants. Lip and facial support are imperative. It is all about the planning. I would suggest that you have a fixed bridge rather than a snap-on overdenture. Snap-on overdentures require much more maintenance to replace the teeth and parts that wearout. A 6 zirconia bridge is ideal in your circumstance but you really need to be treated by an expert. Clink on the links that I have provided to get you up to speed

  2. Hello Doctor Amin!
    I hope allis well!
    I just had the alone four procedure on the bottom jaw and noticed a significant amount of bone loss due to bone leveling. Due to this, my face lost a good amount of volume and I have the sunken in face look. Luckily, I am still in my temp’s and will be fitted for my permanents very soon!
    Can you please tell me what can be done in this type of situation when the face looks sunken in? Do I have options and if so what are they? I know that I asked my doctor in the very early faze if he could ad more pink tissue to the piece to fill out my tissue and he said, no, you would need filler. This is actually alarming to me because in all my years researching this procedure, I learned that having your bite corrected and having dental implants can fill out your lower jaw and help correct your lost vertical dimension.
    I just don’t understand why he would not want to add pink tissue in width to help fill out this area.
    Thank you so much! Your advice will mean a great deal!

    1. Hi Nic,
      I have to say I totally disagree with your doctor. That being said this is a true skill in order to maintain facial/lip support. I do some very extreme cases and . My suggestion is that you go through another set of temporaries in order to prototype all of this. In my practice we use surface and facial scanning technologies to make sure that I can maintain or improve somebody’s facial appearance.

      Stay safe during COVID 19!

      Ramsey A. Amin, D.D.S.
      Diplomate of the American Board of Oral Implantology /Implant Dentistry
      Fellow-American Academy of Implant Dentistry

      1. Oh Dr. Ramsey, You have no idea with what I am dealing with!
        First off, My dentist doesn’t look at me. He look’s up in the air when I speak, and when he speak’s! How can he not look at me when he should be studying my face, the way I pronounce certain word’s, and estichally how my face look’s! My sister said he probably think’s I’m soo pretty and get’s shy! I say, that’s just my luck!
        I should mention that I had all on five on the bottom jaw, with a denture on top. My top jaw was prepped with bone graft’s for future all on four procedure and to prevent bone loss. My surgery went extremely well and I am healing nicely!
        However, I have not worn my top temp denture since the day I got it due to the fit and the look of the teeth! I have a very wide, brood, small line, and the teeth on the denture are very small and narrow, I call them possum teeth! I explained to the doctor that the denture does not fit and that I can not speak with them in my mouth because the top of the palette actually lay’s on my tongue. He blamed this on me having a flat pallet and a arch with a great amount of bone volume! I know that temp’s are temporary, but I assumed he would reline them, or make me a new temp since I couldn’t even wear them to eat or to protect the open wound’s, but he never did, not even a mention of it!
        He actually shaved my lower teeth (bridge) because they would hit into my raw upper gum line at night when I would sleep. He said, well since your not wearing them, and he filed away! I was stunned!
        I asked him if me not wearing a top denture would be a problem with causing a more collapsed bite and possible bone loss from me pressing food against my bone, and he said no! But I got to tell you, with all I researched, I learned this to be un-true, am I right?
        At first I was ok with because of the mask we have to wear hide’s my face, but now I’m just like, I have been to him four time’s since getting new impression’s, how could he not care that I leave his office the way I do? Knowing I’m not wearing a top denture and for month’s now! And, I’m starting to look old, and wrinkly!
        He also has no advice for me when it come’s to my wax try in’s. Shouldn’t he hold teeth by my face, helping me choose what tooth shape is good for me and my face structure? Also, I go for my second wax try in in a week, and he has not taken any measurement’s of my face, the distance of my nose to my lip, nothing! Shouldn’t this have been done already?
        When I first met with him, I brought a ton of younger photo’s of when my smile and teeth were beautiful, and the first thing I mentioned to him was that my face meant everything to me, and aside from getting my gum’s healthy again, I am more interested in preserving my bone, increasing my VDOO, and a dental facelift with the new set of teeth he would make me! So to think after the fact, he tell’s me he won’t fill out my face with material and I would need filler seem’s almost ignorant to me!
        I will ask him about putting me in new temp’s as you mentioned in the previous message, but what I want to know is, am I pressing my luck asking him to do this, or is this his obligation as my dentist?
        I am really pretty, but Dr. Ramsey, my face is withering away since my surgery, and I am scared to death he is not going to make me look good or restore it, but worse!
        Also, What if in the early planning stage he didn’t plan correctly and this is why he is saying he cannot do anything more with the new bottom arch???
        If My message to you seem’s like I’m talking to one of my girl-friend’s, please forgive me, I’m just so frustrated and really needed to yenta ball before I really lose all hope! I must admit, I get kinda timid when I talk to my dentist about the work, but having you and this amazing blog with so much information is giving me some courage!
        I do hope you can touch on some of the complaint’s I have mentioned and as usual any advice would be greatly appreciated and be put toward’s helping me achieve a brighter and prettier future!
        Thank you,
        Nic

        1. The prosthetics on full mouth replacement teeth are very challenging. I think you saw the case of facial and lip support post already. It sounds like you and your doctor do not “connect” well. Maybe you should consider seeing somebody else just to finish the teeth? There are plenty of times that I have finished the teeth for a case that the surgery was done elsewhere as long as the implants are well done.

          You need to go through at least 1 or 2 prototype’s until you can get your pretty face back! Keep in mind that dental implants will never be the same as are natural bone and teeth so it is an attempt to balance biology with prosthetics. Sometimes we have to have an aesthetician do some dermal fillers/Botox to get the final look that we are going for. This is usually not necessary but give it some consideration

          The VDO that we call vertical dimension of occlusion is critical to be right. This is what gives the face youth or an elderly look. I am assuming you are doing fixed bridges rather than removable over dentures.

          Ramsey A. Amin, D.D.S.
          Diplomate of the American Board of Oral Implantology /Implant Dentistry
          Fellow-American Academy of Implant Dentistry
          Burbank, California

          1. Hello Dr. Ramsey,

            Again, thank you for getting back to me! It does mean a lot! I have been learning from your literature and insight for many year’s now, It is truly an honor speaking with you!

            I think your right about me and my dentist not connecting well! To be honest, I kinda felt it in my gut from our first one on one consultation, but I was just so excited and anxious to finally have the procedure done! I waited many year’s and sacrificed alot for this, as I’m sure many patient’s do!

            Yes, you are correct in your assumption’s! I am having a zirconia porcelain permanent bridge on my lower jaw, I am still in my first temp’s as we speak until my permanent’s. I do have my second wax try in for my upper removable denture in a few day’s. The plan is to complete my top removable denture, before working on my bottom permanent bridge.

            I do understand the idea of having botox and filler in combination with the dental work. My concern is that the bottom temp was made extremely narrow and more u shaped, with the lack of facial support. At the moment, it look’s like I don’t even have bottom teeth, for the exception my bottom lip. I am of German/Syrian decent, with high cheek-bone’s and a strong jawline. I purposely kept the root’s of my broken teeth in, to preserve my bone and prevent my jaw from resorbing. I knew how important this was to keep my bone structure. But now after the bone leveling and the teeth removal, my bone resorbed a great amount, leaving my face with no framework, all putty.

            If I did choose not to complete the teeth with my original dentist, does he deduct the cost and give me a reimbursement?
            I payed almost all up front, with a small payment due when I OK the permanent’s.
            And is he obligated to provide me with a second set of temp’s upon my request, or would I be lucky if he agreed?
            I would Just love to have you do my top’s when I am financially available! Or maybe even just my teeth! I have no doubt you will make me feel beautiful again!

          2. Hello doctor Ramsey Amin! I hope this message find’s you well!
            So, I took your advice and went for a second opinion regarding the issue’s I’m having with my dentist!

            So upon taking your advice I went to a lab that has been in business for 40 year’s and who made teeth for several people I know. The first thing I asked after he looked at the work in my mouth was if the implant’s were properly placed and if he could work with them. Fortunately, he said yes!!!

            So, after speaking to the denturist and explained everything I was having issue’s with, he to agreed on the following: the temp’s and wax try in’s did not match with my face structure, the bottom teeth were made way to small, and the lower arch was extremely narrow as well as not having enough “synthetic GUM” to fill out my facial contours, and when made properly corrects VDOO and facial collapse as well as sagging.

            Although I was extremely delighted with the confidence he displayed and his desire to make me a fantastic set of all on five zirconia bridge and top removable denture, I was hesitant to make an onsite decision. Below are the reasons why.

            Based on his evaluation, he recommended that my dentist do the following; give me a newly created bottom all on five lower temp before starting the top temp, or complete the permanent zirconia bridge on the lower Jaw before starting the top temp’s wax try in.
            He explained that however the top teeth are made, the bottom teeth have to be fabricated so they can fit perfectly into/onto one another; and because so much need’s to be changed and altered on the bottom temp I am currently in, creating the top permanents first will serve an injustice with esthetics and function.

            He said if I were to leave my dentist and have him make the removable denture and permanent bridge, he would choose to do the bottom and top teeth together and that this way would be the better way of making them. So, top and bottom wax try in at the same time, and go from there until we get the finals.
            What do you think? Do these few option’s make any sense to you? Would a person get better results by completing the permanent lower bridge first or completed together? Does this sound like a good idea?
            I know I read somewhere on your site, that in order to achieve the proper lip facial support and correct VDOO, it is all pre-planned before surgery as well as arranged by properly creating the top prothesis first. So would this pertain to every case, or depending on the situation for each case is different.

            I will have to make a decision soon, but I wanted to hear your thoughts on the matter before doing so! I fear that completing them together or bottom first is an incorrect way of doing it, as I couldn’t find any information on this matter the three week’s I have been searching.

            As usual your reply is so greatly appreciated and I am forever grateful to you and I always try my best to pass the kindness forward!

            Please know that any advice you should give me should be taken as common knowledge in the field of dentistry and should not be considered an online consultation, diagnosis, nor a second opinion.

            I figured I would put that disclaimer up there I just in case if what I asked was to unique to my case.

            Thank you doctor! You are the most wonderful!!
            TTYS!
            Nic
            P.S. I’m a girl

  3. Maybe you have an answer for this, I just don’t know. I recently had a bone leveling procedure done after having a molar extracted. In my case, it was because the extraction left a bump in the gum that was very painful. The procedure was done just a little over 2 weeks ago at this point. I am still in quite a lot of pain and now where it was once a hill there, there’s no a valley. Did he take off too much? Is this pain normal after 2 weeks? I’ve had ongoing issues with the right upper side of my mouth for 5 months now and I’m very tired of the pain.

    1. bone leveling is not commonly done for a single tooth implant. It is more common for full arch implants. Pain at two weeks is not mormal for simple procedures. Hopefully you are on an antibiotic at this point.

  4. Dear Dr. Amin,
    Thank you for the very informative blogpost about alveoloplasty.
    In your experience, does alveoloplasty contribute to
    facial collapse? I’m scheduled to have an alveoloplasty of
    the lower jaw whereby 6 mm of jawbone will be removed.
    After that, 4 dental implants will be placed as well as an overdenture.
    I’m worried that when I take out the overdenture, my lower
    lip will collapse into my mouth. Is this a valid concern?
    Would it be wise to choose a bar-retained overdenture
    instead of a ball & socket attachment system so that the bar
    compensates for the loss of height?

    Thank you so much for your advice!

    1. the rules are very different for implants placed between teeth versus implants placed on a jaw that has no teeth. The bone that used to support the teeth is very thin and easily dissolved over time. It is far better to have the minor alveoloplasty to have stable implants over time and to try to preserve this unstable area. This is a process I’ve done for about 20 years with extremely great success. Regardless of the alveoloplasty when the denture is taken out your lower lip will fall in. A lot of this depends on your skin thickness or thinness. Typically women have thinner skin… no pun intended 😉

      By doing this you are much less likely to develop peri-implantitis over time which would then lead to possible retreatment or a redo of your entire case.

    2. To go through all the trouble for a bar retained over denture is crazy to me. For that same cost you can be restored with upper and lower fixed implant Bridges that you never have to take out. Not plastic, hybrid denture teeth. Locator abutments is a more cost effective and excellent maintainable option for over dentures with a much reduced cost.

  5. Thank you, doctor Amin, for the very informative article. A question I had while reading it:
    doesn’t alveoloplasty contribute to facial collapse? I’m scheduled for an alveoloplasty of the
    lower jaw in which the oral surgeon will remove 6 mm off the top of the jaw bone before placing
    4 dental implants (4 mm diameter).
    It worries me that so much bone volume will be lost and that it will significantly age my appearance
    when I take out my implant-retained denture. Is this a valid concern? What is your patients’ experience
    with this issue?
    Would it be wise to opt for a bar-retained denture, so that the bar
    makes up for the loss of bone height and the lower lip doesn’t collapse into the mouth?
    I would really appreciate your expert opinion on this.
    Thank you in advance!

  6. Hi Dr., I received the all on 4 on both upper & lower 2 months ago- I am going back (I traveled out of state for the procedure). when I smile big, you can see the transition of the gum line to the bridge on the lower arch (not in the very front, but totally everywhere else on the bottom) they have assured me that this can be adjusted. they are ‘bulking up’ the new bridges as well due to face volume loss (I wore an upper partial for a couple of years before getting implants. My Q is, is it true this can be done? Or do I need bone leveling? can bulking up help in regards to volume loss?nalso just fyi-you can’t see the gum line at all on the upper, they mentioned something about adjusting my smille/bite by possibly making the teeth a lil longer? this was also the way my smile was when i had all my teeth. I’m feeling nervous about this, spent 10,s of thousands on this procedure-my dentist is very reputable, I’m just looking for other opinions. thanks!

    1. If there was an adequate amount of bone leveling you should be able to do any smile adjustment you need. I am constantly improving, moving peoples smiles during the temporary phase and going through testing before we go through the final. This is also done with a digital video scan workflow to really see facial movements besides just static photography

  7. Hi Dr. I live in Reno Nv and have been seeing my dentist to try and get implants. Latest information is I don’t have enough space for them. I was told ortho could help give me the space needed but was later told it wouldn’t work after seeing the orthodontist. I’ve been asking and wondering if I could just have my bone reduced to give me space and move on to implants but it seems my primary dentist doesn’t respond well to that idea. Seems like my only option. I really would like to have you evaluate my situation. Maybe I can get there someday. How long is the healing process when bone is reduced? Thanks

    1. bone reduction alveoloplasty is generally a bad idea for single front teeth dental implants. This concept is usually used for multiple dental implants that are placed adjacent to one another.

  8. Dear Dr Ramsey A.Amin
    I am sixty years old. one of my lower incisors was lost over four decades . And was told by a G P saying that the space of my bone Gums (less than 2mm)is not big enough for me to implanted even if making bone grafting. Was it ture? And what of the effect is to bone?
    Best regards!
    Paul Liu

    1. if there are teeth on either side and the spaces too tight you run the risk of killing the teeth on either side. Ideally would like to keep a minimum of 1 mm away from teeth on either side of a single tooth implant.

      Ramsey A. Amin, D.D.S.
      Diplomate of the American Board of Oral Implantology /Implant Dentistry
      Fellow-American Academy of Implant Dentistry

  9. Hi Dr . Amin, Thank you so much for your informative articles. I live in Alabama and I would use you if I could go CA. but I am barley getting by and I will have to use a oral surgeon in Birmingham . He has quoted me a price of $ 4,400. 00 for bone leveling . Is that a far price. Thank You Sheila

    1. hmmm…..are the extractions and sedation included in the cost? is just the total cost of your treatment or just of the bone leveling alveoloplasty?

      1. Dr. ? do you have a team in Huntsville Alabama, im about to go full on , on fixing my mouth, im gonna use my credit card,,, but I have been saving up for implants since I was 35, im 49 now, im seing a mini implant Dentist in Huntsville and he recommended, bone grafting, then some mini implants, and some real implants, and I don’t understand a thing he said, or was saying . anyhow, he gave me an estimate which is some 10 thousand dollors and month and months of work… good lord Dr. is it worth going through all that? should I just have partials for my back mouth till I die? im terrified of dentist , that why I waited so long to go at it, Philippines, 2 root canals and 4 extractions at age 12, WITHOUT NOVACANE… it was free.. and my single mom thought it was for the best… im still traumatized, but I feel its for the best…for myself.. but watching your video made me think about all sorts of things.. im shaking right now as I type… what should I do?

        1. Find a great dentist that can just put you under IV sedation and have your dental work done that way. It is extremely common in my practice and you will sleep through the whole process. It isn’t very often that a patient has to transition through miniature dental implants then do real dental implants.
          I hope you have explored all of your options to the fullest extent. There are a number of ways to build your mouth to last for decades and there are other treatment plans that tend to fail about 10 years after treatment.

  10. Hi
    Dr Amin
    After tooth extraction I am having semi liquid food and now soft food with help of jaws. Since last six months. Now some pain has started to my jaws muscle radiating that to head and neck and ear also acidity and naseua type feel but all bearable and for denture I have been referred to oral surgeon as while extraction dentist didn’t do any filing of the bones which has come out please opine in the matter

    1. If you had bone exposure this can cause a significant amount of deep pain. Typically this resolved in 1 month after surgery. This does not happen often.

  11. Dear Dr. Amin,
    I second the post made by Janel Williams and also want to thank you for the information you so meticulously explain in your videos and articles. It has allowed me to educate myself and ask appropriate questions to find the best possible team available in my area. I knew not only what to ask, but what to tell my team to help them understand my situation and goals.
    Thank you so much for your time and extending everyone in this difficult situation your years of knowledge. I will also tell all my friends and colleagues from California where to go when they need treatment by an expert and gifted educator.

  12. I have been reviewing your website for information. I can not afford to see you but I want to tell you how wonderful your site is and how much I appreciate reading the information that I needed to know. I will recommend you to my friends and family in LA when they need the services you offer. Again, thank you for making this information available to everyone. Your expertise is amazing. No one else I talked to seemed to be able to give me the information on options for dentures and implants that you have on your site. I have been feeling very confused and uncertain. It makes me feel less frightened and more hopeful about my advanced gum disease. Thank you.

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