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CERECDOCTORS.COM
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QUARTER 3
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2015
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D I S C U S S I O N F O R U M
exfoliated.Thefirst surgical procedureconsistedof debridement
of the site, bone grafting cortico-cancellous allograft (MinerOss)
coverec with a Cytoplast PTFE membrane, and PRF applica-
tion. About three weeks later, there was a small wound dehis-
cence exposing a small portion of the PTFEmembrane. I waited
another week and then removed the PTFE membrane, as I do
not want to leave any exposed PTFE membrane in situ longer
than four weeks. If you look at the removedmembrane, you will
see the small area that appears yellowish and that is the infected
part of the membrane, with the rest appearing white and non-
infected. At the PTFE removal procedure, I placed another PRF
membrane on the immature regenerate (no collagen membrane
although that would have been feasible as well).
2014: Six months after the second bone graft procedure,
I placed a Straumann Bone Level implant guided with the
CEREC Guide. As you can see, I cut off the handles of the
CEREC Guide keys to avoid any distortion of the CEREC
Guide thermoplastic material. The implant was then uncov-
ered two months later, at which time I took an Omnicam
scan with a Glidewell ScanBody to have Glidewell fabricate
a screw-retained BioTemp. One month later, the implant was
restored with a screw-retained crown by the patient’s GP.
2015: One year follow-up with PAs and post-op CBCT scan.
Crown-to-Implant ratio:With an 8mmStraumann implant,
I am not concerned about this since studies have not shown
this to be a factor with Straumann implants of at least 8 mm
length. However, I would be concerned if this was a Strau-
mann or Astra 6 mm implant, as I have not had much luck
with those as free-standing non-splinted implants. Bicons
are probably a whole different situation - and short Bicons
appear to do very well - but free-standing, non-splinted, ultra-
short (6 mm) Astra and Straumann implants don’t (based on
my experience and based on a few published papers).
Farhad
BTW: This entire case is also part of the second CEREC
Guide 1 video series in the digital learning section (video #12).
CARRIE POLSTER
Wow, I am amazed at the intricate analysis you all
are giving. Very impressed. I don’t do surgery, but still
very impressed. I amusing premier implant cement.What do you
think of that cement? It cleans up well at 2.5 min set. I have only
had two implant failures inmy practice but that’s two toomany.
FARHAD BOLTCHI (FACULTY)
Thank you everyone for the kind words. I am kind
of surprised that only Ken guessed (albeit in a
shotgun approach) that thismayhave beendue to cement sepsis.
Althoughall the other causesmentionedarepossibilities, when I
see something like this, cement sepsis is No. 1 onmy list.
Here is the whole story:
2006: This patient presented with a failing lower left FPD.
I extracted tooth #20 and, approximately three months later,
performed the staged bone grafting with a mixture of mineral-
ized allograft, Bio-Oss, and autogenous bone obtained with a
bone scraper from the retromolar area (no PRP or PRF in those
days). Thiswas coveredwithanOssixPlusmembrane (not tacked
down). OssixPlus is a highly cross-linked collagenmembrane.
IMO, it is the best resorbablemembrane available as it is the
slowest resorbing (up to 1 year+), yet it doesn’t get infected if
it gets exposed. It went off the market for a number of years
since the company producing it in Israel was sold and the new
owners didn’t care much about the small dental market place.
It came back on the market again last year and is now avail-
able through OraPharma.
2007: Patient waited approximately one year before
proceeding with implant placement, which was fine with me;
typically, the longer you wait, the better the bone graft results
will be. I placed two Astra implants (of course non-guided in
those days).
2008: Patient waited again about eight months for insur-
ance reasons before having the implants restored by his GP
with cemented PFMcrowns on stock Astra Direct abutments,
which I had placed. We performed a final POT in my office
after the final seating of the crowns and all was W.N.L. We
dismissed the patient to the care of his GP.
2013: Patient was referred back for evaluation of bone loss
around one of his implants. In interviewing the patient I
found out that in 2009, the patient’s implant crown on the #19
implant had become unseated. He went in to see his GP who
was not in the office that day. The GP’s assistant re-cemented
the implant crown and everything appeared fine. The patient
then moved to Boston for several years and had just recently
returned back to Texas when he started noticing an issue with
the #19 implant, which prompted him to go see his previous
GP who then referred him to me again.
2013: Between the time I sawhimfor the initial evaluation and
thetimeIsawhimforthesurgery,theimplanthadspontaneously
