Removal of a Titanium Implant with Peri-Implant Disease and Replacement with Ceramic Zeramex XT Implant

Dr Toffler: I am curious about the morbidity reports, not just histologic findings, that I have not read for these types of cases. I am curious as well: what health changes occurred for the patient when she had the implant removed. It reminds me of when we discovered that mercury in silver fillings was cytotoxic and as of yet don't have RCT's, Systematic Reviews nor Meta-analysis to confirm that it is causing health problems. we certainly do have knowledge about the cellular toxicity of both amalgam and composites. I'm not judging your point of view: I am reminding myself that we have to be certain that "where we are changing to" is truly better than "where we've been". FYI: My understanding is that this site is not for promotion of materials nor of professionals credentials. It seems to be centered on helping dentists that are early in their learning curve, know more about implant dentistry and problem cases.

There are a few points to make here. The evidence that titanium components can cause these issues is not well established, it’s more a hypothesis that needs scrutiny. Zirconia implants have quite a history in implantology, indeed they were proposed right at the start of dental implantology for their bio-compatibility. But to date Titanium based systems have captured the vast majority of the dental implant market. New style Zirconia implants are gaining a market share at this time, but they have some inherent dis-advantages which need to be taken into consideration. They can be rather brittle and can fracture in use. It is difficult to make two-part Zirconia implants which remain stable over the long-term because of this problem. Notice also that most of these implants come only in larger sizes, for Zeramix with platform diameters of 4.2mm and 5.5mm. One-Piece Zirconia implants are often described as being “Preparable” which is tough work indeed, and which may weaken the implant. Removal of a fractured Zirconia implant can be an extremely difficult procedure. First it’s difficult to visually differentiate the implant from the bone surrounding it. Second, burs, trephine drills and saws generate high temperature spikes when they touch the Zirconia and at the same time instantly become blunt and useless. As a result, the bone defects left after the removal of zirconia implants tend to be larger than those left after removal of titanium implants, because the only way to remove them is to cut a channel around the outside of the implant. Finally, it should be noted that there are ways around some of these problems. There is one implant, manufactured in France by TBS called the Z1 implant which is made of Titanium but which has a Zirconia collar in the trans-gingival region. But most implant systems these days have the potential for a Ti-Base connection which will receive a customized Zirconia sleeve which can be designed to give the desired emergence profile and restorative preparation while giving the superior gingival appearance reaction that Zirconia gives over Titanium. We use this technology for all our restorations, not only for the permanent restorations but also for Immediate Placement provisional restorations.

Not Cool to do promo here. Time wasted!!

I think this subject is one that anyone placing implants these days needs to take seriously. Yes, it is true that the research re the systemic toxicity of Titanium is sketchy at best At the same time I think we need to keep an open mind about this and also to honor those individuals who have serious concerns about a toxic systemic reaction in their body in response to a metal such as titanium. We are doing people who have this concern and labeling them as "over-reactive" or as "one of those crazy anti medical establishment nerds" a tremendous disservice if we do not take these concerns seriously, and continue to objectively look for answers

Quick note: Nothing is being promoted here, and nobody pays to post cases on this website. We ourselves (not the doctor) added the bio of the doctor, and some information about the implant used in the case, because we thought that information would be of interest. If you don't want to know anything about the person whose case this is, and what implant was used, feel free to skip that part, and focus on the case itself. If you have comments on the case, either good or bad, please feel to share them. Thanks. PS There are other links in the post for additional articles and discussions that maybe of interest. Specifically, there was a post about a week ago, related to this topic that had some interesting feedback: Dental Titanium Implants and Chronic Inflammation

There are pros and cons to all we do. There is far more information about Ti implants than Zr, but to balance the argument- why not read: J Biomed Nanotechnol. 2019 Apr 1;15(4):728-741. doi: 10.1166/jbn.2019.2717. Toxicity Induced by Zirconia Oxide Nanoparticles on Various Organs After Intravenous Administration in Rats. Sun T, Liu G, Ou L, Feng X, Chen A, Lai R, Shao L. Abstract ZrO?-NPs are widely applied in industry, biomedicine and dentistry, e.g., foundry sands, refractories, ceramics dental prostheses, dental implant coatings and bone defect restorative materials. To date, little information is available on the potential adverse effects and toxic mechanism in human organs associated with exposure to ZrO?-NPs. The biodistribution of ZrO?-NPs and the consequent oxidative stress in the spleen, kidney, heart, brain, and lung at six time points after a single injection of ZrO?-NPs were examined. Histopathological and immunohistochemical changes were also examined. RNA-Seq analysis was conducted in organs with high ZrO?-NPs accumulations or obvious histopathological changes (brain and spleen). Exposure to the ZrO?-NPs led to persistent oxidative stress and cell proliferation promotion/inhibition in various organs. RNA-Seq results of the spleen and brain point to significant gene expression changes. Metabolism was identified as leading pathways in the spleen. This study proves ZrO?-NPs likely have negative impacts on various organs, and exhibit potential disease risks.

Titanium...….Titanium dioxide (TiO2), also called titanium(IV) oxide or titania, is the naturally occurring oxide of titanium. A white pigment, titanium dioxide is used in paints (as titanium white or pigment white 6), and sunscreen because of its ability to refract light and absorb ultraviolet rays. According to the U.S. Geological Survey, 95 percent of titanium mined is turned into titanium dioxide pigments, with the remaining 5 percent going into manufacturing chemicals, metal, carbides and coatings. Titanium dioxide is also commonly used in medicine, cosmetics and toothpaste, and is increasingly being used as a food additive (as E171) to whiten products or make them look more opaque. Some of the more common food products with added E171 include frosting, chewing gum, marshmallows and supplements. There are no restrictions on the use of titanium dioxide in food products. However, a new study on mice, published in the journal Gut, shows that titanium dioxide particles may be very damaging to the intestines of those with certain inflammatory bowel diseases. Researchers at the University of Zurich in Switzerland found that when intestinal cells absorb titanium dioxide particles, the intestinal mucosa of mice that had colitis became inflamed and damaged, according to the study news release. Inflammatory bowel diseases such as Crohn’s disease and ulcerative colitis have been on the rise in Western countries for many years. These conditions are characterized by an extreme autoimmune reaction to intestinal flora. Several factors play a role in the development of the disease, including genetics and environmental triggers such as lifestyle and nutrition. Now the Swiss researchers have found that titanium dioxide nanoparticles, commonly found in toothpaste and many food products, can exacerbate this inflammatory reaction to an even greater degree. In addition, higher concentrations of titanium dioxide particles can be found in the blood of patients with ulcerative colitis. This means that these particles can be absorbed from food under certain disease conditions, explain the researchers in the news release. Though the findings have not been confirmed in humans yet, the researchers suggest that patients with colitis should avoid ingesting titanium dioxide particles. Since the poster of this case mentions from the getgo that his patient suffers from severe ulcerative colitis....it is not fair to blame her reaction strictly to the implant in her mouth....as she is being bombarded with titanium dioxide particles from many sources including tooth paste, makeup, sunscreen, etc…….so to condemn a titanium implant for her problems with the metal ...is not entirely fair....Zirconium is fairly new on the market.... we have not yet heard of bad reactions to this substance yet, but I am sure we will very soon......in the meantime ,let us not discount the usefulness of titanium be it as a hip replacement or a tooth.

Thank you, Dr R, for this informative post..This is the kind of material that we need to share with those patients who believe their body is being poisoned by their titanium implants, or who are considering zirconium as an alternative to titanium. I think giving patients information like this is so much better than just blowing off those patients who are expressing some reservations about having titanium as the material of their implant. I say let's give our patients the most current information and let them make an informed decision. Thank you again Dr R

I agree with Dr G! "Not Cool to do promo here. Time wasted!!" But I would like to see more cases by other companies as well, like ceraroot and Z-systems. I have seen the results from the plastic screw Zeramex uses and the restorative hardship caused by the connect. Maybe some side by side comparison would make this platform here less like a paid advert.

This is a very important subject, one that most of us will be dealing with more and more in the days to come. Why don't we focus on the subject and let go of criticizing the poster

Correct Dr C., I was not informed that Zeramex would share my case on this site. This is the one and only ceramic implant I have ever placed. I am not a paid consultant for Zeramex nor am I yet a strong proponent for the placement of non-metallic implants. I am intrigued with the possibility of alternatives to titanium implants but still in need of comparable long-term results. I am promoting nothing. A more beneficial discussion would center around the possible patient concerns with titanium and the management of the reduced subantral bone height as well as techniques available to perfom the simultaneous membrane elevation Dr Rudick your posts are informative and colleagial. Thank you Michael Toffler

Good discussion. True metallophobics will not want to know that zirconium like titanium is a metal. As are most of our ceramic products. We still need to accept that there are allergies to various metals and alloys. Keep an open mind, what we known would fill a book. What we don’t know would fill a library.