Nobel Biocare Replace Select Implant Fracture: Treatment Plan?

You will have to trephine this implant out. Watch for the nerve. Once out, graft and try to get primary closure. Come back in three to four months w a new implant.

I have had replace select fracture on me before. There are many documented cases of this. Unfortunately, you will have no other choice but to remove the implant. Dr. B is correct, where you will have to use a trephine to remove it, and graft the area. Good Luck

remove the implant, I would not graft, the area will be filled with bone after few months, I prefer to implant in the future in natural bone rather than grafted bone. then you have the following options: 1. to place another implant 2. to cantilever on the distal implant 3. to make a tooth-implant supported bridge weigh which option is suitable for your case and go on good luck

First of all reverse torque. If that doesnt work i would furrow around with either a very narrown bur or piezo. Ok augment only if youcan get closure> However if you augment wait 6 months for the augmentation to vascularise. No less than 6 monbths!

yes, implant is useless- needs to come out in least traumatic way possible. Piezo, burr, trephines, whatever. Removing implants can be very challenging. You cannot apply reverse torque here because the hex is shot. Just remember that all techniques will heat bone and expect some dieback. Primary closure shouldn't be an issue here. More importantly, why do you think this exploded? Replace connections can break, although it is rare in the wide platform. The bone loss around the implant suggests a chronic process. Perhaps the crown abutment construct became loose and the patient was functioning on it for some time. Notice that the distal half of the abutment screw is still in the implant. Any thoughts?? Occlusal scheme, parafunction?

listen to those guys that posted first... Nice photos btw.

Looking at the wear of the surrounding teeth and the occlusal shape of the adjacent crown, I would almost guarantee you have a significant occlusal factor contributing to this fracture.

I have seen this type of fracture with the narrow platform Replace Select tapered implant (3.5 mm). As stated by others, it is documented with this small diameter implant. I have never seen it happen on the 4.3, 5.0 or 6.0 mm sizes. I agree, use a trephine with copious irrigation to remove it. Nobel does have a special instrument to thread into the implant for removals, but I am unsure if it would work in this case due to the fracture. As for replacement, I have always grafted the site and returned later to place another implant. However, it is not out of the realm of possibility to place a larger diameter implant, once the original has been removed at the time of removal. Just watch the IAN, as it is close. Since it is a mandibular case, you may want to consider a parallel walled implant (Replace Select Straight?) which could get better stability at the bottom of your osteotomy.

If you are able to remove the remnants of the screw, Nobel has an implant retrieval tool that doesn't require that the tri-lobe platform to be intact in order to remove the implant. The threads of the tool are reversed so when you reverse-torque the implant, the tool engages the inner chamber of the implant and unscrews it. There is much less trauma to the patient if this technique is possible and you can graft the site, place a slightly wider implant, or close the site and wait for natural healing, as you choose. Good luck.

I have had it once before with a different mark of implant and this one had a history of becoming lose and an unwilling patient to let me deal with this problem until it was broken. The implant has to be removed and treat it as a socket preservation technique, let it heal and place a new implant. By the way I would never trephine this implant out: to much bone damage. Osteo-intergration is strongly overrated and since you can grap the implant after you raise a little soft-tissue flap with a forceps, I would take the implant with the extraction-forcept and turn the implant for 1/4 to 1/2 turn in to the bone. This will brake the osteointergration and then you can turn it out with less damage and less risk for the nerve ( maybe some compression trauma): good luck

Unfortunately the only option is removal of the remaining portion of the implant. Then graft allow to heal and a new fixture can be placed. Contact Nobel and see how they will handle the fracture and need for a new implant. Now there are two options to removing the implant, first remove the portion of the fractured screw in the fixture and Nobel should have a tool that will thread into the remaining portion of the fixture then using a counter clockwise motion it maybe able to unthread the implant from the site. If that doesnt work then the only other option is to trephinate the fixture out.

You need to find out the cause of the fracture, otherwise, you may need to deal with the same situation again after another implant is placed.

Look ! Do not make this a big deal. Take this as an opportunity. Trephine out teh implant and place a slightly wider impant immediately and do not load and graft as needed. It is not a science project

I agree with what has been said about the surgical removal of the implant. However, when I look at the occlusal surfaces of the natural teeth there seems to be quite a bit of wear on them. That in conjuction with the rather large crown on a narrow platform implant probably led to it's fracture. I would consider placing a larger implant when you re-treat. There may also be some wisdom in doing a splinted 2 unit screw retained prosthesis in this area. An occlusal guard would also not be a bad idea. Although, not a daily occurence these types of complications do occur. Thank you for having the courage to share it with us.

You already have the answer to your question. I would warn the patient on the risk of paresthesia of the lip as a complication of surgery. Reverse torque of any form will not work as implant is osseointegrated and been there long.

First of all you have to ask the patient for Dentist information who placed the implant. I think the cause of failure is an over-torque, more than 45 Ncm at the moment to place implant or more than 15 ncm at the moment to do the prosthetic job, breaking the connection implant chamber. In my experience, this case could have two ways to get a diagnose: 1) the over-torque problem or, 2) could be a typical example of prosthetic job without original brand abutments or abutment screw. Nobel has a color scale to differenciate sizes, an special abutment screw and an implant retrieval tool kit; so, retrieve the implant, fill the form if you are succeed about previous dentist information and got a new implant without cost and ask manufacturer to apply 5 year guarantee. Wait the time for bone rehab and place the same implant size or that which your dental planning treatment allows. Good luck, regards to all.

I agree that trephining is the option of choice. I would suggest that you trephine down to just beyond the end of the internal screw hole which coincides with the beginning of the greatest taper. Then you should be able to unscrew it with some fine root forceps. I can't see how there would be any risk to the mandibular nerve by doing this. This is a perfect example why internal connection implants aren't as good as the manufacturers make them out to be, particularly if they are made from CP Titanium, as this implant is, and not from Titanium alloy. I have NEVER had a Titanium alloy implant break. If you want to use internal connections, then use an implant made from Titanium alloy.

Nobel does manufacature their Replace implants from CP Titanium - this makes them prone to fracture under pressure. Try using Implant Direct's version of Replace called Replant. They make the exact implant from Titanium Alloy so it wil not fracture and it is self tapping for dense bone, which is typically where fractures of this nature occur with Nobel Replace implants. Trephine is best option and make sure to graft with mixture of Mineralized Cancellous particulate graft and B-TCP (Cerasorb) to maintain integrity / socket dimensions. Wait 6-8 months and go back in with a Titanium Alloy implant.

You have a complex problem here. What is the eitology? Occlusal forces, crown or abutment coming loose? I agree with comments already posted. In my experience, the least traumatic way of removing this implant is to use the Nobel Biocare implant extraction tool. It essentially works by applying reverse torqueing forces to break the osseointegration bond and back out the implant. But if you are not experienced with it, you may wish to refer the patient to someone with experienc in its use. I would elect to add bone graft materials to the site and to undermine a buccal flap by split thickness dissection so that the flap can be advanced to close to the margin of the lingual gingiva. Again, if you are not experienced in this type of surgery, you may wish to refer the patient to someone familar with this technique.

This was a relatively small diameter implant with a full size molar restoration. The most likely reason for this was that the ridge was considerably resorbed when the implant was placed. Trephining the implant out will be liable to destroy both buccal and lingual walls, making for a defect that will be hard to repair. Consider removing a small buccal window, tap the implant from lingual to buccal and remove it. You will then be left with a three-wall defect where it may be possible to place a new implant immediately with concurrent grafting for the buccal wall. Good Luck.

Entertaining comments; Cantilever from the back implant?! It broke because more than 45 NCM ?! LOL

This case was placed 5 year ago 2006,implant fracture occurs after 5 years in function.I think was happened here was the abutment screw is loose, and lateral occlusal force overloads higher than normal to break the implant platform in buccal side. This narrow platform implant 3.5 is not indicated in posterior mandible. Is the only platform that can break from nobelbiocare if not following the manufacturers intructions. Removed implant with combination of surgical burs and trephine, if you Have enough bone in lingual side.go deeper with surgical burs around the implant to be the most conservative possible then when is more than half of the implant body use the trephine .in the way will have less damage to bone and less postoperative pain, get implant out , after bone grafting and implant back to the regular real platform 4.3 for posterior madible cases.

its already mentioned what are different ways of managing such situation. looking at occlusal scheme its a surprise that implant were not splinted. also if narrow implant were used diagnostic set-up should have narrow mesio-distal width so that you can plan relatively narrow premolar size clinical crown. in other worlds reducing space b/w tooth-implant and implant-implant to 2 and 3 mm repectively. also it be worth going back to surgical placement notes to see how much insertion torque was applied. nobel 3.5 are know to split even with high insertion torque so problem might have started at placement. bone loss is chicken and egg issue ...split fracture can cause bone loss or bone loss lead to fracture

It looks like overloading,because i can see the shadow around the neck of ＃45 implant.So my opinion is that, the first option is try to take screw out,splint two implants; second is make the #45 like the post crown. Be careful of the bite occlusion.GOOD LUCK!

A few things to plan for immediate removal- attraumatticattly if possible- use microscope- zeiss, get implant retrieval kit, osseointegration is easily broken, remove remaining screw, unscrew the implant preservation- of the remaining bone, graft as needed, reposition split thickness buccal flap/ use mucograft for close approximation of the flap- no need to obtain primary closure- all depends on what you want to do. rehabilitation- immediately provide for an occ splint, verify for parafunction, due course 6-9months place implant , later restore, new splint. Periodic review

These types of incidents should be reported to the FDA medwatch program. This is the only way the agency knows where post market problems exist

i think that this type of failures,usually related to force factors and the amount of crestal bone loss.in other types of implants, it can be seen.

Remove the hopeless implant , wait for bone healing, then place another implant. I would definitely consider splinting the crown to the posterior implant for extra support.

Hello Remove the implant with the trephine & if u can put a new implant (Wider Diameter) immediately. Wait for 6 months & then load the implant but keep the crown just out of occlusion.

Not necessarily the width as what you are best able to use is often guided by the ridge width but the tri-lobe system which has a weakness in the narrower implants in the range. But a challenging removal, good luck. Peter

Neobiotech makes a fixture remover kit that will help you remove the implant without trephining out. I think Zimmer sells it too.

i unfortunately have had two replace implants fracture upon placement. The first being a 3.5 at a lower incisor region. Thank goodness the Nobel Rep was down the street with the appropriate tool and it was quite easy to back out. I was able to place the same diameter implant , just 3 mm longer and it worked out beautifully. My second experience wasn't so good, in that the platform sheared off at final seat of a 5mmx13 in very dense bone . The patient was a pediatrician that became disabled after a stroke. The back out tool did not work, and trephining wasn't an option, so I cut the implant down, slowly with supercooled irrigation, leaving a 5-6 mm hole. I then harvested a significant amount of autogenous bone and mixed it with prp and closed it with a gore membrane. A second implant was placed approx. 6 mm distal to that one . An another implant was placed uneventfully on the contralateral side of the mandible, to accommodate a bar/ overdenture. The man has been in function for three months with no evidence of breakdown over the buried implant. I definately was torqueing greater than 50 ncm's, but I feel like these implants should be able to withstand this type of force. Biohorizons advertises implants that can withstand greater than average torque values. I'm afraid some of nobel's products are slipping through quality assessment to easily. I have never had a strauman, biohor., snap off. Again, I have to pose the question regarding reverse torqueing an integrated implant, my experience is limited, however, in that I do not restore the implants. Bv

What were your torque values when you were seating these implants? Nobel Replace Select is notorious for excessively high torque values leading to either fracture when placing or exaggerated crestal bone loss because of crestal bone microfracture. Paulo Trisi just published an excellent paper in JOMI with histo relating torque values and bone microfracture. We are now moving towards lower torque values in implant placement to preserve bone and shorten the catabolic phase of bone healing. There is a new implant cutting thread designed by Intra-Lock, International. This new feature is called the Blossom(r) thread which is a symmetrical helical tap so that the implant body cuts through bone very efficiently. This will minimize bone microfracture and lowers insertion torque to within the physiologic zone. An article by Frietas, et al (Clin Oral Impl Res Nov 2010), actually correlates this lower insertion torque with INCREASED initial stability because there is more vital, intact bone in direct apposition to the implant surface. RJM

if you want to continue to use Nobel at high torque levels, I would suggest switching to Nobel Active...great implant...or switch altogether to another company. That being said, Nobel is about to release a replace select implant with an internal tapered hex connection, same as there active connection in order to address these fracture problems

Changing the internal connection does not solve the ultimate problem with Replace Select; that of excessive compression of bone. Virtually every paper published recently demonstrates histomorphology of the relationship of torque to bone microfracture. High torque value on seating actually results in significantly REDUCED initial stability at one week and beyond. This design is well past it's prime. No amount of window dressing is going to change that. RJM

Tricky situation...the implant seems pretty close to the nerve. You can try trephining then luxating it out carefully or go down 3/4 of the way with a trephine bur then use a piezosurgery to remove rest of the bone around apical 1/4 of the implant. Piezo will not sever the nerve or the vessels in the canal if you were to 'overshoot.' Good luck.

I have seen a similar case with the same type of implant. I have stopped using Nebel Biocare some years ago. My patient had it placed some years ago, elsewhere, and came to me to have it removed. The bone loss around the implant was so extensive that the implant could be removed with hemostats. The inherent weakness in the design (tri-lobe) with the weak areas seemed to have snapped. I suggest removing this one. Trephine or whatever to about 1/2 way down the length of the impalnt or more. Then use a chisel or a periosteal elevator and mallet to loosen the implant. Once it becomes loose, you can try to unscrew it with hemostats or ???. Expect some trauma to the area.

Mallet gently and sideways. Good luck.

As far as I see the abutment screw is in still the implant. Why not remove the screw (easyly with reverse rotation) aplly a fiber post in the screw hole with resin cement and make a composite core over it to support a regular metal -ceramic crown? What is there to loose?