Patient requests removal of a titanium implant and replacement with a ZERAMEX XT implant

Case Presentation by Dr. Michael Toffler

Case Presentation by: Michael Toffler, DDS | New York, NY |  September 2019
Site #3: Patient requests removal of a titanium implant with peri-implant disease and replacement with a metal-free Zeramex XT implant

Michael Toffler, DDS  is an experienced Periodontist with a demonstrated history of working in the health wellness and fitness industry. Strong healthcare services professional with a certificate of residency in Periodontics from V.A. Medical Center West Los Angeles. He is a Diplomate of the American Board of Periodontology and is well published in refereed journals and has written textbook chapters on sinus floor elevation and it associated complications. 

“There is presently a lack of information if and how titanium (Ti) particles from dental implants affect the tissues in the oral cavity, particularly peri-implant tissues such as bone and connective tissue cells” (Happe et al 2019).


  • Ti particle pollution may be perceived clinically as discoloration of the marginal tissues and histologically, we see lymphocytes in the peri-implant tissues with increased Ti concentration (Zipprich et al 2018)
  • Ti particles can provoke a dual effect, reducing bone formation due to inhibition of osteoblast proliferation and increasing bone resorption by IL-6 osteoblast-mediated osteoclastogenesis (Goodman et al 2016)
  • Titanium wear microparticles shown to activate osteoclastogenesis (Mishra et al 2011)
  • A recent cell culture experiment demonstrated a cytotoxic effect of Ti debris on human osteoblasts and gingival fibroblasts (Happe et al 2019)
  • If Ti particles create an inflammatory cell response or induce bone resorption they may play an important role in peri-implant disease.

Case Report

  • 30 y/o female with history of severe ulcerative colitis. For the last 1.5 years, she has experienced: periodic fever, muscle aches and weakness
  • Implant # 3 placed with transalveolar lift in August of 2017 by another periodontist
  • Patient presents in my office with 25-30% bone loss and 6-7 mm probing depths implant #3. She now wants the implant removed as she feels it may be contributing to her condition.
  • ENT confirmation: no sinus pathology present.

4 months after implant removal and grafting the residual osteotomy, there is a subantral bone height of 3-7 mm and a convoluted sinus floor

Toffler Case Presentation Picture 2
Toffler Case Presentation Picture 3

3.5 mm Densah® bur spins CCW 1200 RPM to autograft and lift sinus prior to finalizing with ZERADRILL®

Toffler Case Presentation Picture 4
6mm stop
Toffler Case Presentation Picture 5
8mm stop
Toffler Case Presentation Picture 6
Lift at 3.5 mm Diameter
Toffler Case Presentation Picture 7
Final prep wih 5.5 x 8 mm ZERADRILL & TAP

Placement: 5.5 x 8 mm Zeramex XT implant slightly distalized to engage more subantral bone.
Collar: .6 mm
supracrestal on mesial and distal, 1.6 mm on facial. Sinus lift: 3-5 mm

Toffler Case Presentation Picture 8
Toffler Case Presentation Picture 9


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