Nobel Replace Select Implants

Fixture may be encapsulated with fiberous tissue. removal and replace a new Replace. Replace...Replace...Replace

There is a reason why they call them Replace.

I would allow at least 6 months of osseointegration before testing the implant again - inform the patient that replacement of the implant maybe needed due to the soft bone.

the dental implant will be rejected, as the body would recognize it as a foreign body once it has moved, my advice... remove the implant, prepare the site again to remove the encapsulation tissue, and place longer and wider implant if possible.

Try to use a parallel wall implant which has not so much insertion torque sensivity!

This implant is not osseointegrated. It has a fibrous connective tissue attachment to the alveolar bone. Waiting will not improve the osseointegrationation at this point (it may if it's early, ie weeks post op). In these instances, I have removed the implant and debrided the site, and immediatly placed another implant (try to go slightly largerand longer if anatomy will allow). You may have to go with another manufacturer to "upsize the implant " just slightly. If you want to use only Replace and can't "upsize" the implant then graft and wait 4 months. I wouldn't graft and place the implant simultaneously, as I have not seen good results with this technique. Just my humble opinion.

Replace them now or replace them later. This is a common problem with these implants. The best day of my life is when I stopped placing the Noble implants. Just too many problems!!!!!!

No question, replace the implant and wait six months before loading. The standard protocol almost always works. Don't rush it. Your patients will be happier if the implants work the first time. Also, I do not necessarily agree that there is a "normal" amount of die-back. I personally use the Zimmer TSV system. With this system, the widest part of the implant is at the first thread, not at the platform. Therefore, when the implant is fully seated, there is little or no lateral pressure on the surrounding bone (much like the situation with a cylinder-type implant). When the standard 3-month lower and 6-month upper protocol is followed, I have noticed no radiographic bone loss at he osseous crest. I have hundreds of pre and post load radiographs to substanciate this. I have, however, noticed a small amount of die-back when I place the secondary screw at the time of implant placement. My only thought is that the screw may be distorting the implant enough to place some pressure on the surrounding bone. I am seriously considering returning to the standard time-tested protocol for all of my implants. Twenty years of implant placement have taught me that introducing additional risk for the sake of convenience for the doctor or the patient is not necessarily the way to go.

I agree with Larry S, if the implant spins at 3 months it is not integrated and a radiograph will not necessarily show a fibrous encapsulation at this stage. Remove it and if possible prep longer and wider( 5.0 mm diameter ). I disagree with the guys that automatically bash Nobel Biocare or the Replace implant. Its not the implant, its the technique of placing the implant. Its the care and attention in the planning phase, the surgical placement and the post surgical care. Most or all major implant systems will integrate, the science is pretty clear on that. There are differences between systems necessitating slightly different surgical and restorative technique. If an implant system is used appropriately there will be very few failures.

There is a big difference in tappered and straight wall implants. Tappered has a problem for the clinician looking for initial rigid fixation. Straight wall is better. Replace is something I stopped using years ago.

I would suggest the opposite is true, tapered implants give more initial stability than parallel sided implants. This is one reason Replace Select is approved for immediate loading. In fact in average or greater bone density it is important for the surgeon to fully prepare the osteotomy including use of dense bone drills and/or screw taps to ensure the insertion torque isn't excessive.

Steve M and I see things similarly. I would add that, on rare occasion, the patient loading the implant prematurely (thur noncompliance) can be a cause of failure. The Replace is not my #1 implant, but the Replace Select Tapered Groovy (don't you love that name?) is a very good implant from a surgical and prosthetic standpoint. Tapered implants are my first choice, especially if immediat provisionalization is anticipated.

A Replace Select Implant in the maxilla is at its most vulnerable 3 months after placement. After initial stability at placement, osteoclastic activity occur to varying degrees around most/all implants. The recommendation for loading Selects that are not immediately loaded, is 6 months after placement. I've had this very thing happen and removed the implant and observed perfect threads in the bone. I rinsed and replaced and 6 months later it was integrated.

I am sorry, a taper is like a "V". If you unscrew the implant a turn to relieve pressure you are lifting the "V" out of the "V" osteotomy. You loose fixation gentlemen! A paralleled wall implant will allow for multiple turns out of the osteotomy and you do not loose initial rigid fixation.

There is little research to support any of the above technical suggestions. My own (anecdotal) suggestion: if it was loose by hand torque only - i remove and wait a few months, then replace the implant. If tight by hand but loose only when torqued/counter-torqued to 35 newton-cm to confirm osseointegration, I allow a full 6 months of healing (typically another 2-3 months from 'planned' abutment placement). No research, but a reasonable plan with reasonable results in our group practice.

First, I would not attach any importance to the posters bashing the Nobel implant. Second, I did not read that you said they were tapered or parallel, yet many assumed they were tapered. The Nobel Replace come tapered and straight walled, and I like using the straight wall for 90% of my applications. Third, I am assuming these fixtures were placed into healed sites because you did not say they were placed into an immediate extraction site. Fourth, in a completely healed site with mature bone and >35Ncm insertion torque, three months is long enough for the Nobel Replace Select to have integrated, although the strength of the osseointegration has not peaked. This would not be the case in an immediate placement-longer osseointegration time is needed. Fifth, and to answer your question, this implant will never integrate. Remove it now. You have choices regarding its replacement. One is to go up one size in diameter and place it right away. The other is to wait for the site to heal and do a guided bone regeneration either before or in conjunction with the insertion of the new implant. Going up one size will probably work and take the least time, but the second option, while being much more time consuming will most assuredly give the better esthetic and functional result.

regarding tapered or parallel implants the initial stability lies in the type of bone you have and the way you prepared the site with your drills according to the density of the bone. Some tapered implants have wider and bigger grooves at their body and at their apex and this will improves the initial stability of the implant for example ankylos implant from Degussa/Dentsply for your problem after LA ,torq it maximum and leave it 6 months

Stop using the replace implant!! The reason it failed(and they all will)is due to the implant abutment junction(the micro-gap)is VERY LARGE and it harbors the periodontal pathogens.You must not place the microgap below the gingiva. The will fail due to periodontal disease.

The analogy of the "V" and the tapered Replace Select implant is inaccurate. A tapered implant or at least the Replace Select can easily be backed off a couple of turns and it will still have more initial stability than the average properly placed parallel sided implant. I have to assume that the one making this analogy has not placed tapered implants.

You assume wrong. Think about it. Create an osteotomy in a pig mandible with a dense bone site for a straight wall implant, lets say 13mm length. If you left the implant high in the osteotomy 4-5mm, would it still be rigid in the bone? Yes, as the fixture left in the bone is being compressed and fixated laterally on the vertical axis. Try the same with a tappered implant. You would be able to lift it out by hand as the osteotomy is wider at the top of the osteotomy and there would be no compression on the 8-9mm left in the bone. There are minimal threads with little depth to the thread on the select at the apex or bottom third of the implant. Surface area is less on a tappered implant versus a straight wall implant of the same length. The bone implant contact is less. Do we not want as much contact as possible? Please, make a statement with some logic behind it. I am sure you are a great clinician but you are making statements that just don't make sense.

I disagree with steve M's post. As a general rule the parallel or straight implant is bound to offer better initial stability than the tapered ones on account of the increased area they get for integration. prhaps a look at htis article may be of some use (J Prosthet Dent 2005;94:377-81.)its an excellent review on biomechanics & factors affecting integration

I appreciate your comments on initial stability of tapered implants and I respond with interest and sincerity. Also I am not commenting on long term stability after the fixture has integrated fully. I have never needed to adjust the vertical position of an implant by as much as 4 or 5 mm, and I agree that with this amount of change a tapered implant would not only be less stable, but it may actually lift out of the osteotomy. In a clinical setting an osteotomy is prepared as precisely as possible including its depth ,and this depth is related to the selected implant length, adjacent tooth or implant position, surrounding bony contour,and amount of interocclusal space available. In most instances an adjustment may be only a portion of a mm or up to 1 mm and never as much as 4 to 5 mm. Also, the taper of the thread dimension in a Replace implant is less in the coronal portion of the implant than in the apical third, so a small vertical adjustment as would ordinarily be needed in a clinical situation, can be made without significantly affecting stability.

Well said Steve M however 4-5mm was used to explain the differences. In fact, it was a suggested experiment. I am commenting on initial stability not long term! Clinicians want the tactile sense of initial stability. A straight wall will always have a better tactile sense of initial stability versus a tappered implant becuase of design. Necrosis can occur when forcing an implant to engage with rigidity. I am sorry, you are not difinitive in your statements. "vertical adjustment can be made without SIGNIFICANTLY affecting stability strongly suggests that you will loose some stability. You and I unfortunately cannot say how much but if stability is being lost potential risk of failure increases.

I have only had one Replace Select Tapered spinner. It was the middle abutment (#8) in a 3 implant 6 unit bridge. It started turning as I fitted the permanent abutment (cemented case) so I tightened it again to slightly over 45 NCm and fitted the metal/acrylic prototype bridge at that point. Two months later it was firm again (not spinning at 35NCm)and the clinical signs and radiographic appearance are quite normal. This apparently lucky re-integration is presumably due to the rigidity of the temporary bridge.

Dr. Furst: 1). The implant in question either had a very thin fibrous layer or had a minimal amount of bone-to-implant contact on a microscopic level (was not "fully integrated"). Roberts, et. al. have shown that integration continues for 18 months, with coated, non-coated, etched, machened, etc. implants all reaching equivalent bone contact at 12 months. An implant that is not fully integrated will start to turn during torqueing by fracture of trabeculae. Such an implant will "re-integrate" if left to heal for an additional 6 months. Unless you have a radio-frequency analysis system in your office there is no scientific way to determine which of the two situations you have. You can make a good estimation however. If the implant required quite a bit of torque (30-35ncm) to turn and actually unscrewed with each turn then it was probably partially integrated. If it just spun in the osteotomy (even with a fair amont of torque) you have a fibrous encspsulation. 2). I have placed over 5000 implants, including Branemark, Zimmer, Biohorizons, Straumann, Replace Tapered, and Replace Straight (parallel wall). Each has it's own advantages and disadvantages so quit comparing apples and oranges. There is no "best" system. 3). By design a compression screw, when placed properly, will have better intitial stability than a staight screw (any engineers in the group?) Replace Tapered is a compression screw. 4). The first 6mm of a Replace Tapered is parallel. It is designed to be backed out 2-3 turns without loss of fixation. I have done this hundreds of times. Good luck with your case.

The answer to the question which implant design offers optimum initial stability in soft bone, straight or tapered, is dependent on the surgical protocol. The best would be an evenly tapered implant inserted into a socket prepared with an undersized straight step-drill so that the soft bone can be compressed and yet the narrow apical end still engages bone.

I am in total agreement with the comments of Dr Gary Kitzis. In addition, I would also add that whether or not the implant is replaced right away, the socket must be debrided of all soft tissue first. Also, the remaining labial plate may also be a factor to contend with. In other words, the replacement implant must meet the requirements of correct implant placement.

There is no such thing as "normal die back". The reason for the die back is due to the micro-gap at the implant/abutment junction that harbors these periodontal pathogens. WHY PLACE THE JUNCTION SUBGINGIVAL??? Nobel has the largest gap of 15 microns and oral bacteria are only .8-1 microns. Think about it, Replace and Replace.

It's just a lost implant like many others!! Tapered or straight, made by Nobel or other company, sometimes we loose them...

Regardless of whether the microgap is 15 microns or 8 as is claimed by Nobel Biocare, or 5 as claimed by others, all these gaps are larger than the bacteria and there will be an influence if placed below the bony crest. Sub gingival isn't such a big issue as long as it is well above bone. Of course there are other important issues responsible for crestal bone remodeling that need to be better understood and controlled. I'm confident this issue will be solved in comming years.

In my hands, comparing the Replace Select tapered implant to the Branemark straight implant, the Replace implant is more stable in the vertical direction during placement. One factor that has not been mentioned is the design of the apical end of the implant. Replace has a smooth and blunt tip, whereas the Branemark has the cutting sides at the apical end. I suggest that the cutting apical end of the Branemark or similar design of other implant systems contribute the feeling of less definitive apical "stop" that I feel with Replace.

Replace it!

In your hands just use a nail for everything. There is no need for a screw. The blunted tip is like a nail tip. The Branemark apical end will have threads that give some of the fixation in the apical aspect of the osteotomy. Ask yourself why is it easier to pull a nail out of wood than pulling a screw out of wood with a hammer? Tapered implants work but not as well as straights for initial fixation. Sorry you suggest wrong.

About this screw versus nail stuff, you really need to compare threaded nails to screws. Which is what a screw is moron, a threaded nail. Anything threaded has greater pullout strength, doesn't take a DDS degree or whatever specialty program you graduated from to realize that. Ever heard of biological width? Whoever calls it die back or whatever, need to go back to basics, or go to more weekend courses on implants. Ever think about trusting a surgeon that just learned how to perform brain surgery over the weekend? or wish that he stayed at a holiday inn the night before.

Dear Dr. Furst, you know what happened and what you should do if an implant spins 3 months after insertion, we all know. Soon we will experience failures of new implant protocols based only in marketing and attracting doctors throughout technology.There is no reason to speed up osseointegration based only on materials and surfaces. The bilogy remains the same and sometimes innovative techniques might be considered to improve osseointegration,but today´s the main implant reference are the expertised sales personnel from companies. Many of the design of the recent studies do not conclude propperly and companies invest money to obtain quick results.

There is no reason to speed up Osseointegration? Unless of course you are a patient who doesn't really want to wait 6 months for a result that could be obtained in 6 weeks or less. It seems that some view osseointegration the same way others view pain. It doesn't really bother them to make someone else uncomfortable, even when the technology is available to reduce that discomfort. After all what does the patient know? Hopefully their neighbor hasn't had a less painful and time consuming experience. I bet Burger King exec's expressed the same sentiments when McDonalds opened the first drive thru. "Customers don't need that."

So the apical end that has thread does not give you a feeling of "stop"? However the the blunt, basically no thread stops. You are putting all your trust in the coronal portion to fixate. Tissue necrosis can occur when added pressure is applied to get that "stop" feeling you describe so eloquently. It occurs when there is no "stop" sensation and you increasingly rotate the implant looking for the "stop" feeling. You have no idea what you are talking about. The screw vs. nail analogy is reffering to the appical end of an implant ONLY. Please go read a book at the holiday inn where you must be employed.

“In my hands, comparing the Replace Select tapered implant to the Branemark straight implant, the Replace implant is more stable in the vertical direction during placement. One factor that has not been mentioned is the design of the apical end of the implant. Replace has a smooth and blunt tip, whereas the Branemark has the cutting sides at the apical end. I suggest that the cutting apical end of the Branemark or similar design of other implant systems contribute the feeling of less definitive apical "stop" that I feel with Replace.” That was my post and the only post in this thread. A couple of posts that followed were unnecessarily hostile. I suggest that in this type of discussion we should stay civilized. Sharing knowledge, arguing about disagreements, and point-out in accuracy is OK, but throwing insult at each other is not.

Dear collegues: I teach and place Replace Implants since the very first prototypes where available in the spanish market (Steri-Oss external hexed on that time). The Replace Implant was originally designed to be used in immediate placement after the extraction of a tooth. The systen became so popular that the company thought that this system will be suitable for any indication including healed sites and hard bone. They came out with the 3.5 implant (Magenta) and the system was completed. A tapered implant is a compressing screw desing that works very well in soft bone (sometimes in combination with osteotomes in very soft bone), also using an HA coated surface will help in this situation. Most of the problems with Replace implants came with the insertion of such a tapered desing in hard bone, some of this implants will brake before reaching the final position (Ti Unite implant are made out of pure titanium and are less strong than HA coated implants wich are done with titanium alloy). The company changed the threadformers 2 or 3 times to solve this problem they had with hard bone and finally came out with dense bone drills and another thresdformer design (I personally use the ones designed by Peter Worle wich are Titanium Nitride covered-gold-). My preference is to use a Tapered design in the maxilla in wich I take advantage of the tapered design (better stability, narrower tip, different diameters that fit any teeth to be replaced etc). In the mandible I use a paralel wall screw design (ie Branemark MkIII) wich was designed for hard bone mainly. When to load my implants is a decission I do after measuring implant stability and evaluating every case but my protocols are very simple and if I don´t load them immediatelly I still wait 6 months in the maxilla and 3 months in the mandible. I have to asume that I am doing immediatelly loaded implant more and more when I think that is an indication to do so, but I wait for the rest. By doing this I have excellent implant success ratios. My advice will be extraction of the implant, wait three months and place a new one . then you will be in the safe zone all the time.

Please, unless you want unwanted law suits, you had better tell your patients, especially the women who are taking Fosamax, about the down-side of dental implants and Fosamax! This is just the tip of the iceberg!

Has anyone experienced a microfracture of the top (occlusal polished surface) of the Replace Select 3.5 mm.implant?This occured during insertion with the implant driver on a handpiece. Can this still be restored or will the fracture definitly extend? The tooth was a lower lateral incisor.

A fractured implant top cannot be recovered from and should be avoided by knowing the strength of the implants you are using compared to other commercially available implants. A number of postings on this line documented fractures with the 3.5mmD Nobel Replace Implant. The reason for these fractures with Nobel's 3.5mmD Replace implants is that the walls are only .009" thick at its weakest point which is 0.262mm or about the thickness of two human hairs. In addition, because TiUnite cannot bond to alloy, Nobel must use the weaker CP titanium while using Alloy for the same implant with a HA surface. Implant Direct makes a titanium alloy 3.5mmD implant (RePlant) that is both surgically and prosthetically compatible to Nobel's Tri-lobe Replace Implant. We will also be making a 3.7mmD implant with the same 3.5mmD platform, increasing the wall thickness by 44%. Unfortunately, the Nobel 4.3mmD implant is not much stronger than the smaller 3.5mmD Replace implant because Nobel enlarged the Tri-lobe along with the diameter of the implant so that the wall thickness of the Nobel Replace implant is only .012" or 0.3mm. Implant Direct is also making a surgically and prosthetic compatible to Nobel's Replant Implant with the 4.3mmD platform out of alloy for improved strength. In addition, Implant Direct is offering a 4.7mmD RePlant+ implant with walls that are 66% thicker at its weakest point than Nobel's 4.3mmD Replace Implant: .020" vs .012" = 166% Both the 3.7mmD and 4.7mmD RePlant+ implants are surgically compatible with Zimmer's Screw-Vent drills and Implant Direct's Spectra-System drills, while offering prosthetic compatibility with Nobel's Replace Implants. Both the 3.7 and 4.7 RePlant+ implants provide a platform switching interface as the implant tapers in from 3.7mmD body to the 3.5mmD platform and from 4.7mmD body to the 4.3mmD platform.

I would like to know if there are any article on replace and microgap problem. I am confused cause I spoke to a faculty member(GPR). I'm working on a case and said he prefer Replace Select, another Dr. said he heard it has Microgap problems, when i went back to tell the faculty he said that doesn't matter that all implants have that problem. I am confused and want the best for the patient. If micorgap is an issue , is there literature refering to it and replace select? Thank you ' concerned recent graduate

welcome to implant dentisary it just show that Nobel is no better then the others

all implants today are created equal Replace, 3i, strauman, what ever. I've never heard such bull--- from some of these implant morons, Lets just keep to the facts. Some will work some will fail and i don't care what the name on the box says. Take the implant out, curretage the fibrous liner out of the threads.That's why it moves and replace the same size add some PRP if you like and believe in this product. I've done this several time over many years and for some reason the second time seem to always work.

I agree with the Portuguese dentist! Short, simple and practice. I just thing the use of tapered implants should only be use in cases of pour bone volume and density of the apical position of the apex of the implant. Why we not use the realy good basal bone with a paralel disign and spend bone and dangering primery stabiliy with a conical implant?

Answer to the question: "Why we not use the realy good basal bone with a paralel disign and spend bone and dangering primery stabiliy with a conical implant?" Not all tapered implants are the same. Your statement may be true for tapered implants like the Replace from Nobel that is put in with a tapered drill but is not true with an implant like the Screw-Vent or Implant Direct's new implants where the taper is over the entire body and the socket is prepared with straight step drills. As you stated, the tapered implant has advantages in soft bone but only if the narrow apex is inserted into an undersized socket prepared by the intermediate drill allowing bone expansion. In dense bone, the final drill is of a large enough diameter that a bone tape is not needed and the implant will self tap because so little of the threads are engaging...which is all you need because after all, it is dense bone.

To dr. Niznick: and what is the difference between your tapered drill and Nobel's standard and dense bone drills?

The difference between Screw-Vent and ScrewPlant drills is that they are straight with a step-down in the bottom 3mm of the drill while the Nobel Replace Drills are tapered like the implant. There is also a difference in the tapers of the implants...the Screw-Vent and ScrewPlant start their taper near the top while the Replace implant is tapered only in the bottom half and then goes straight up. The even taper allows for a more gentle bone expansion in soft bone. The the drill diameter and design for the Tapered Screw-Vent, was made with this in mind and the new ScrewPlant has the added advantage of tapering from 1mm from the top rather than 2.5mm from the top with the Screw-Vent. The RePlace Hard bone drills was an afterthought because of reports of bone loss from overcompression. The Screw-Vent drills have not changed since they were introduced with the tapered implant in 1999.

RE: Replace Select HA Tapered 4.3 x 13 A colleague claims deep placement in mandible near neurovascular bundle and mental foramen is possible if you remember to drill short and then seat apical tip at bottom of osteotomy. This is not discussed in Nobel guidance manual. I'm not comfortable since the Nobel warning about the drill being 1mm longer than the implant is there for a reason. My colleague claims no problems with self-designed protocol and many others he knows do it in the mandible to get longest implants in. Maybe straight groovies, too. He gave example: to get a 13mm implant 11mm into bone, he drills 10 and seats the implant at 10. He says he drills the thread tap a little deeper to enable seating in type 2-3 bone under 45 newtons torque. But there is no shaft marking at 10 for any of the drills so depth is a guess in a dangerous place. So, should the apical tip of a RS tapered be seated like this or should I leave the gap? He also often leaves maybe 0.5mm of the HA out of the bone (supercrestal) in this setting, another uncomfortable situation. Opinions, please, appreciated. Barry

Remove the implant, wait three month and place a new