NobelActive: Best Implant Fixture for Immediate Restorations?

And what does he base this on? Is there research on this implant to allow this type of a conclusion? What is "Initial Stability", and is having the implant "more" stable better? We know nothing about this because there is not yet data, on an implant that is being placed in my Mother and yours. How long will this implant last? WE DON'T KNOW!!!!and neither does Nobel....least of all a rep.

I won't spend too much to buy a open secret

There are several implant design that are excellent for immediate restoration. Such as LaminOss from Impladent, MIS-7 from MIS and AB dental's root form. Do not forget plateforms and subperiosteal and ramus frames. I do pose a topic for thought about the zirconia implants. They may be too stiff, thus the modulus of elasticity may differ so much that the bone will exhibit disuse atrophy.

You may want to take a look at the Ankylos system from Dentsply. All of the case studies that I have seen have shown this to be an excellent choice for immediate loading and bone actually grows up over the color. Little no micro-gap in the conical connection means that don't see the typical 1mm recession after placement. I would definitely check it out.

Nobel active was invented by Alpha Bio. First Nobel bought the implant. Then, last year they bought Alpha Bio. So i was paying 100 Euro for SFB -Alpha Bio. Now they have changed the name and the bill. A company from Israel is reproducing it exactly- and it costs 80 euro.

All very interesting information, can someone who has used the Nobel Active implant answer the question though? Are there any disadvantages? I'm also curious and already know about most of these other systems.

I have used over 50 Active implants. I find the stability to be the best of any system and the easiest to use surgically. My main Implant is Astra and I will not switch easilly. The platform is conical and similar to Astra and Ankylos. I find stability of the active to be better than the aforementioned and the ability to change position of the implant surgically is a huge advantage. I generally place temp abutments and temp crowns or bridges immediately, often when the teeth are extracted. So far one failure out of 50. So, I am cautiously optimistic as it seems like an excellent solution for immediate stability and replacement yet long term studies are unavailable. Disadvantages: costly, prosthetics not as good as Astra and the thread is so aggressive with thin buccal bone you can actually displace a large portion of the buccal plate, so you better know how to augment ridges!

I have seen the initial Nobel Active presentation at an AAID meeting several years ago. I have not used any to date...I am sure they are excellent. However, what is really terrific about this implant, is how the four partners of Alpha Bio got Nobel Biocare to buy them for one hundred million dollars. If machined with infinite precision, proper sterilization, etc; most of the implants on the market today are variations of Titanium Alloy, and one is good as the next. In my opinion, immediate loading of any implant system is like walking on a sidewalk of not fully cured concrete....if you are lucky, it might carry your weight, if you are not lucky, it will crumble, and you might get hurt in the fall. Hats off to the four Israeli dentists who invented the original of the Nobel Active.... they are truly the best marketers in the world.

c.g. I have been using the NobelActive and have had very good results thus far. The biggest advantage is the primary stability for immediate loading and routinely I'm able to torque the implant in at 70+N. I'm not sure if this has any scientific impact but clinically the higher torque values are leading to favorable results. Is it possible to do this with other systems, Yes, but I have found it easier with this system. Plus I like the restorative aspects of this implant. I use some other systems in my office but have found this system as my "go to" system. Disadvantages include it may be trickier in the mandible than in the maxilla. But once you do a couple cases you know how to use the implant...just like any other system.

Former Nobel Biocare rep here. The surgeons I know that used these implants complained of precisely preparing the osteotomy only to have the implant go wherever it wanted. Initial stability was said to be hit and miss. The biggest problem with this implant is the idea that Nobel is marketing it as an every indication implant. Sure...for $387 per implant and 62 dollar healing abutments we should be putting these implants everywhere right? At best this implant is for teeth 8, and 9, using a tricky palatal wall compression surgical technique, and for extraction sites. This implant should supplement something you already use....Not replace it. The only science that is available on this product suggests higher bone loss, and lower success rates than that of the Replace implant. The advantages over replace are that there are less restorative parts since there are only 2 platforms, and the collar is stronger for less fractures than replace. Also platform switching, but again, studies thus far indicate more bone loss, so throw out that advantage for now. This thread seems to revolve around Initial Stablity. What good is initial stability if SECONDARY stablility is poor?....ie..2 days after placement, 1 week, 4 weeks, 10 weeks, 25 weeks? If you look at Nobel's own Resonance Frequency Analysis data on tiunite it takes 25 weeks for its RFA values to get back to initial stability! (Glauser et al. Applied Osseointegration Research 2001; 2:27-29) There are many implants out there that are more stable after only 1 day, and have stronger osseointegration using reverse torque testing than Nobel's TiUnite surface. This surface is 2 generations behind. Macro geometry = initial stability, Surface technolgy = secondary stablility. Many of those implants shockingly cost less. Food for thought. Beware of buying marketing fluff. Personally I think Initial Stability is a red hearing. Secondary stablity on the other hand is completely underated. Nobel Active is a niche implant that has big nasty threads, that make you believe its better. The golf industry, and Fishing industries have been using that marketing tactic for years.

Very nice presentation Allan. CAn you tell us which other implants are more stable after only 1 day, and have stronger osseointegration. And what about the surface technology? Thank you

The implant Nobel Active is just another marketing strategies for Nobel Biocare to "lead the market." I personally believe that the market is saturated worse by this company, do the following enumeration, Nobel Biocare said to be the world leader in innovation and research, but all that does is saturate the market and confuse your customers with commercial and scientific concepts that are ambiguous, since talk of research and evidence, but this is not the result of their own but of rigged procedures, the which we want to sell the market as a panacea. Why do not we wonder what happened to the Nobel Direct? The Nobel Speady? Will this company be to hide its failures in commercial and scientific smokescreens and commercial traps, showing the Nobel Active implant of the future? ? Seven of the implant MIS was developed first and that the asset has more research and the cost is 50% lower. Just look at sales results in certain countries and they will realize that the power of NOBEL just in the paper, since the reality is that this will be another failure.

To Dr. Bill Withers: Well expressed and excellent points to consider.

Your rep is not actually placing these implants. He is regurgitating what his company has told him to say to do one thing: SELL. I use a lot of Nobel products. I have placed about one thousand of their Replace Tapered. I now place the Nobel Speedy, a parallel version with a tapered tip. I have no problem achieving primary stability with any of these fixtures. Any skilled implantologist would tell you the same thing. Nobel active scares me for a couple of reasons. 1. Those threads are enormous. If they approach a thin buccal plate a dehiscence is likely. 2. The implant goes where it wants to. Due to the under-drilling protocol, it will follow the path of least resistance. Even under guidance the fixture can easily end up in a position that was not intended. 3. As stated by others, where is the research? Nobel is a marketing monster. I am slowly phasing them out of my practice. They care about one thing, and one thing only. SELL!

I've already submitted 2 articles on Nobel Active which will be published in the Journal of Oral Implantology very soon. I'm also a supervisor on a 3-year MSc Thesis on Nobel Actives by one of my residents. I'm personally involved in a multi-center long term prospective study. Since not all the results are out there i'll be cautious in my response here. When the goal is Immediate Loading, then bar none the Nobel Active is a great implant if not the best. However, avoid placing it at torque values over 50-55Ncm. And use lots of irrigation. I'd be happy to offer more insight but i'm waiting for my articles to get published. Don't want to give away too much information. And by the way....Initial stability is NOT a hit and miss as a "former Rep" said. This implant is for EXPERIENCED users and as long as you do indeed have experience then you can PREDICTABLY get Excellent Primary Stability pretty much every time. I'm not saying you should use it everywhere. I rarely use it in posterior sites but it is excellent for Immediate Loading and Immediate placement in fresh extraction sockets (with a slightly modified technique as per article coming out soon). Cheers

Dr. HXA - Strauman has the best surfaces on the market for Hard tissue, but unfortunately also inflames soft tissue due to its roughness. Astra with their new technology has great results. Neoss is an implant that few have heard of yet. Their surface blows TiUnite out of the water. see (applied Osseointegration Research, 2008, 6, pp6-12) and compare that to the Glauser study I mentioned above. The results speak for themselves. Dr. Irinakis - I am not claiming Hit and Miss initital stability....I do not place implants....the only 2 Oral Surgeons who I sold that product to BOTH told me that. It could have been contributed to learning curve I suppose. They are both good doctors. You'll have to take my word for it, but I've been chairside enough to know a quality surgeon from a poor one. Also, as I mentioned before....what good is initial stability of Nobel Active when secondary stability provided by an antiquated TiUnite surface is surpassed by other surfaces? Just look at the studies that are widely available, and are peer reviewed. Nobel in all their ignorance will tell you that TiUnite RULES! The science that is readily available for those who seek the truth will disagree. Respectfully yours, Allan

To DR Tassos . thanks for your comment's . i am too curios could you please let us in on why you limit to 55ncm. i easily surpasds this with the nobel active. I just attended a lecture by Dr. Khayatt of Paris who published a study with much higher insertion values and showed no bone loss. I'd greatly appreciate your comments. Thanks.

Thank you for your comments. Allan, i may have misunderstood your comments. And you are correct in that there is indeed a learning curve for every surgeon with the Nobel Active. I went through it myself for several cases until i figured out how to make it work to the best of its ability. YK, as for your question. Although there is extremely little research on crestal bone necrosis from 'over-tightening" implants in dense bone, i still believe it to be a fact. Hence, in the long term study we're doing with my resident, we'll be analyzing the different torque values in association with any crestal bone loss. If you place implant in fresh extraction sockets then you won't see much bone loss but if you place them in "healed" bone, then i'd be reserved in my opinion. Again...i have to spend some time analyzing the data, but my early experience has me being more cautious and trying not to surpass 50-55Ncm. Don't forget that based on most studies, as long as you achieve 30-35Ncm, you can pretty much immediately load an implant. So the goal here should not be aiming for the highest possible torque (when we don't have the data yet to support such a clinical end point) but rather to aim for a predictably CONSISTENT torque of over 30-35Ncm. And THAT is very very achievable with this system. I wish i could offer you more details but i really can't give out more before my resident finishes her Thesis. Nobel Active is relatively new. So i'm just being cautious here with the torque until my own data have shown me something different. Cheers

Try Ankylos with 25 years of Data. Miraculous implant. You may be wasting good time and money on untried and doubtful stuff. Ankylos is an ideal implant in every way.

The NobelActive implant is a good one. It has a very agressive thread pattern and the threads take a good bite in bone creating good primary stability. In my view however it is not a bone compression implant as has been purported unless the osteotomy is very undersized, in which case any implant will become a bone compression implant. If the osteotomy for the Active implant is only slightly undersized to the implant diameter then the threads simply cut into the surrounding bone and the perimeter bone simply fills in the reservoir voids between the threads, so as I have said, it is not likely to compress bone very much unless the osteotomy is significantly undersized. As to the matter of such a thing as bone compression osteonecrosis, such a concept has been around for a long time yet there is not one single bit of research that verifies such a thing actually exists. I believe way too much concern has been wasted on worrying about bone compression osteonecrosis at the expense of obtaining good primary fixation which is a very important aspect of implant installation.

My friend Dennis makes a very valid point. There is nothing in the literature to support the concept of compression necrosis. What is really happening here is accelerated microfracture of bone that compromises microvasculature. You end up with an accelerated catabolic phase of bone that occurs deeper within the boney housing than around an implant with a lower compression and torque value. It will take 2-3 weeks at best for that catabolic phase to end and anabolic bone growth (aka osseointegration) to occur. With higher ISQ values, you actually increase the length of the catabolc phase. This is why, as earlier posters had stated, initial stability is weaker after the implant is placed. A next generation implant surface is a calcium phosphate impregnated one. It fools the bone into thinking that the catabolic phase has already run it's course and goes directly to anabolic bone growth within days (published). It has a 500% greater bone bonding in a reverse torque pull-out test at one week when compared to 3I nanotite and Astra Osseospeed. If you combine a good macroarchitecture for initial stability, along with the Ossean surface (Inta-Lock International), you have a world class implant system. RJM

Nobel warns that the NobelActive is for "experienced users." That is an admission that it is technique sensitive which translates into more potential insertion problems. Don't you want an implant that has a simplified insertion protocol that puts the right amount of compression on soft bone to still achieve 35+Ncm of initial torque> Don't you also want an implant that is self-tapping in dense bone so you do not need to use a bone tap and loose the high stability you expect in dense bone? Ask yourself why Nobel acknowledge it is technic sensitive? It is because it flares dramatically from its narrow sharp apical end requiring a soft, medium and hard bone drill protocol. If you guess wrong about the quality of bone like one dentist in Vancouver did on two implants, the implant gets stuck in the bone. Nobel knows this can happen as evidenced by the reverse cutting grooves it puts on the implant, not to help self-tap, but to help unscrew the implant. The Vancouver dentist, selected to be an early trainer, stripped the hex trying to remove the implants and had to cut them out with high speed drills. And then there is the tapered neck of the implant that is narrower than the dense bone drills, leaving a trench around the implant. Expect to do bone grafting with every one of these in immediate extraction sockets. I could go on but here is one drawback that even Nobel can not deny. The implant with cover screw sells for over $450 in the US and almost the same design sold by Nobel through its Alpha Bio division in Isreal sells for $70... and if you by in volume you may be able to negotiate free abutments. Oh yes. In Israel, Nobel advertises that the Alpha Bio SPI implant's SLA surface is key to its success while in the rest of the world they tell you it is TiUnite which is key to its success. AND where is the NobelActive External that they cancelled the launch... another brilliant idea.

Gerald Rudick and BILL WHITERS-- Comments are well said by the both of you

Dr. Niznick, Again you hit the nail on the head. Great points to consider. Nobels implants are way over priced as are others. Why buy their implant when you can cut a decent deal with AB or MIS and for implants that have excellent quality. Again I thank you for making implant dentistry possable for the GP's and not trying the closed to GP route like Noble. That has always left a bad taste in my mouth.

To specifically address the questions at hand. 1. "It is the archer--not the arrow". I have placed tapered, straight wall, and tapered-reverse cutting fixtures from various manufacturers, including NobelBiocare for immediate loading. The implant macrogeometry, microgeometry, and nanogeometry all are important to acheive primary stability. However, there are multiple factors that contribute to successful immediate loading and eventual osseointergration followed by successful prosthetic rehabilitation. This specific implant in question, NobelActive, can be used for immediate loading if other parameters are met-which is beyond the scope of this posting. The general keys are experience in understanding bone physiology, wound healing, dental materials, occlusion, appropriate provisionalization, bone and soft tissue management, radiographic interpetation,and laboratory support. In my opinion, immediate loading of any implant or better yet any implant by any manufacture should not attempted by novice implants operators without appropriate training in this specific technique. Skills are achieved over time and experience-start with two stage protocols before attempting these procedures. The Academy of Osseointergration did a meta-analysis in 2007 on this topic and was published in JOMI. This was an early meta-analysis with other papers following in JOMI and other implant related journals on immediate loading demonstrating success with multiple systems. Relative to literature-there is now a significant amount of literature on immediate loading of multiple implant systems with various implant geometry but care needs to be taken relative to success. It would appear that "success" is possible with immediate loading when compared to a two stage protocol. I hope this answers the posting questions without trying to commericalize, advertise, or creat bias as others seem to be in their non-response to the specific questions at hand.

In my opinion, as someone who has been teaching and manufacturing implants for 27 years, if you can drill a round hole in an adequate width of bone using a drill that only cuts round holes, determine what final drill to use based on the density of the bone, stop at a score-line on the drill and screw in a self-tapping implant with a medium rough surface, achieving 40Ncm of intial torque, you can place implants with two-stage and one-stage healing or immediate temporization. If you are splinting 4-6 implants across the midline, they can also withstand immediate load. The key for the manufacturer is to properly design the implant with the right taper and self-tapping cutting grooves matched to the right diameter of the drills, with drill diameter options for the final drill to be selected based on whether the bone is soft (maxilla), dense (symphysis) or inbetween (manbibular posterior), you will be successful at least 95% of the time. The VA study conducted on 3000 implants from Core-Vent Corp in the early 1990's showed that with HA coated implants, experience had little to do with success. Whether it was the chemistry or the surface texture of the HA remains to be seen but variations in the implant systems does have an effect. For example, Astra with a straight body will not get tighter with more rotations. NobelActive can get too tight and will not seat depending on the final drill used because of its extreme taper. A final comment on: "Why buy their implant when you can cut a decent deal with AB or MIS and for implants that have excellent quality." Why have to "cut a decent deal." Should the price of implants be based on the dentist's negotiating skills or volume purchases? AB and MIS, both Israeli companies that exist today from cloning the Screw-Vent I introduced in Israel in 1986 (add Alpha Bio, Medigma and a few others to that list) are not companies that are trying to compete with the major players on quality, innovation, service etc. They only have to compete on price.

Dr. Nixnick, I was not implying that MIS or AB were hard to deal with. They are willing to make the already attractive listed prices more attractive and without the Dr. asking. The only issue I have with these two companies is that they should make a greater effort to educate the beginner. We all started out as beginners. I also thank you for making your products very competative and of high quality.

This implant can provide excellent initial stability if placed correctly. However, if you need to make multiple corrections in placement with backing the implant out partially, the reverse cutting flutes can destroy the initially tapped threads and you will wind up with a "spinner" that can't be temporized and has to be submerged. There is a learning curve in placing this fixture but once mastered, these go in very quickly and easily. Then comes the restorative part....... My restorative colleagues that have been using the Replace platform since it's introduction are having exteme difficulty with the Active (multiple impression appointments, remakes etc.). The internal hex in the apical end of an 80 degree conical interface really has no straight walls to guide prosthetic component seating. They just cut rounded corners into the slope of the cone so it's really difficult to tell when the impression coping or prosthetic abutment is seated. When inserting components in the Replace platform, copings or abutments will rotate until they seat. With the Active platform, components tend to swivel or tip around the cone rather than rotating since there is no round concentric male tube apical to the internal antirotational element (the hex)to guide placement like in the Replace. This also makes placing Snappy prefabricated abutments difficult because they are so short. In the posterior areas of the mouth I cannot tactilely feel when it's seated due to the swivel effect. Because of this I usually flap the site and seat under direct vision and confirm with a PA xray before torquing One must also exercise care in selecting healing abutments and impression copings when using this implant. With immediate placement and temporization, don't place the implant too deep (>3mm apical to the labial crest). I have found that Nobel's impression copings are wider than the immediate temporary abutment and some of the tissue healing abutments (The 3.6mm regular platform coping that should correspond to the 3.6mm regular platform healing abutment is actually 4.0mm). If there is bone occlusal to the implant shoulder (which I have found due to the excellent hard tissue response to this implant) you will have to reflect a flap to seat the impression coping even if it was immediately temporized or placed as a one stage implant. The labs are also having difficulty with the prosthetics. This is an excellent implant that can give superior initial stability. It is meant however for experienced users that are aware of the issues mentioned above. My only complaint with Nobel is that these issues aren't covered in the procedure manual. I personally will only use it for maxillary anteriors in the esthetic zone in the future.

The NobelActive implant is only recommended for "medium and soft bone" per their own marketing. Since there are 4 "official" classifications for types of bone (Type I, II, III, IV), I assume the conversion factor would be Hard, Medium-Hard, Medium-Soft, and Soft in order to determine where the NobelActive implant is recommended. Their own classification basically exempts placement in the mandible and restricts it to soft and medium-soft bone. Regarding primary stability, there are issues that we overlook via assumption and fail to see when incorporating knowledge we already possess. After implant placement, the NobelActive implant is among the most solid if angle change during placement is avoided. However, during the bone reparative process following the placement injury, osteoclastic acitvity accompanies the osteoblastic integration process. The bone immediately adjacent to the agressive threads lose its grip and the implant becomes much less stable. Intuitively, we assume that initial stability is the floor regarding stability and the osseointegration process is always in a positive direction. The reality is that superior initial stability is far less important than long term stability and maintenance of the crestal bone. Nobel now has a 3 lines of fixtures with hex top, platform, and Morse Taper abutment connections. The new Morse taper line, the NobelActive, is primarily restricted to the maxilla due to the bone type found there. In my opinion, they are still searching for the Holy Grail and have yet to find it. Their marketing department is in overdrive and it is our obligation to pensively assess their product and not accept promotional sales pitches outright.

The NobelActive implant is not quite ready for prime time. My personal opinion is that no implant should be recommended for "experienced users only". Where is the corporate responsibility when inexperienced users, who egotistically feel they are experienced, screw things up and cause irreparable harm to the patient? Secondly, the NobelActive implant is recommended for "medium and soft bone" per Nobel. This recommendation practically excludes its use in the mandible where D1 and D2 bone predominates. The touted "feature" of being able to make angulation changes during implant placement calls into question the quality of surgical planning process. Look in Compendium Magazine, January/February 2010, Vol. 31, No. 1, pg 66-77. This promotional article for NobelActive has disasterous radiographs of finished results. Most pictures document bone loss down to the first thread of the implant. The standard of care today is nearly 100% bone preservation, including crestal bone. I am a self admitted fan of Ankylos. That system has more than 25 years of documented success at the 98% level, primarily emphasizing crestal bone preservation with only 2 design changes in its entire history. They got rid of the polished coronal collar in 2005 because peri-implantitis was not an issue and they added indexing in 2008 without sacrificing the Morse Taper surface area. A modified, self-tapping wall anchor is not where we should be headed.

With the amount of competition for alternative trilobe implants at sizeable price differences Nobel is directing its energies towards Active. We have seen a large influx of general dentist utilizing them and now searching for alternative restorative components. I anticipate the same emergence of nobel active compatible aftermarket components emerging in the worldwide market and overall market acceptance of these alternative solutions.

it is no secret that nobel active is in fact not an active surface implant. This is genius marketing due to the aggressive "active" cutting threads. The Genesis implant system has these same threads along with an actively charged hydrophillic surface. primary stability is good along with secondary. In my opinion the ultimate implant system.

A hydrophillic implant surface is certainly warranted. However, the sole benefit of this type of surface is faster adsorption of thrombin. The will result in faster release of growth factors from platelets. After that, there is no added benefit from a purely acid-etched surface. A hydrophillic anionic bioceramic surface (i.e. Ossean), on the other hand, has the same effect on thrombin/platelets. But it has an added effect of changing the genetic fate of stem cells to become osteogenic lines. The result: faster integration and greater bone-to-implant contact than acid etched implants. I think your ultimate implant system has just been trumped. RJM

I FELT THIS WAS AN EXCELLENT THREAD! Would like t see undates of some of the posters using the noble active system

i agree with the girard feb 6, 2011 post. while often it is best to let dead dogs lie, this would be a great thread to reinvestigate. due to the growing number of nobel active users compared to when this thread originated, i believe there would be a tremendous change in some of the comments as well as the literature support. sadly, i don't believe you could get dr niznick to agree