ask a question Discussing the Latest in Implant Dentistry
Nobel Replace Select Implants
Dr. Furst asks us:
I had Nobel Biocare Replace Select Regular Platform implants placed in #8,9 sites 3 months ago.
When I went to torque down the abutment in #9 it rotated and it produced pain (i.e., a spinner). I had to administer local anesthesia. The radiograph does not show any bone loss around #9 dental implant other than the normal die-back. I am planning on connecting the two abutments with a dental implant bridge. What should I do at this point? Should I wait for more integration or should I just insert the abutments and bridge?
March 21, 2006 in Treatment Planning & Complications | Permalink
Advertisement
Comments
Fixture may be encapsulated with fiberous tissue. removal and replace a new Replace.
Replace...Replace...Replace
Posted by: | Mar 21, 2006 1:05:58 PM
There is a reason why they call them Replace.
Posted by: | Mar 21, 2006 1:18:47 PM
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.
Posted by: Mark Adams, DDS, MS | Mar 21, 2006 1:43:13 PM
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.
Posted by: Portuguese Dentist | Mar 21, 2006 1:56:27 PM
Try to use a parallel wall implant which has not so much insertion torque sensivity!
Posted by: German Dentist | Mar 21, 2006 2:16:46 PM
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.
Posted by: Larry S. | Mar 21, 2006 3:29:04 PM
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!!!!!!
Posted by: | Mar 22, 2006 4:30:05 AM
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.
Posted by: David C. Garrison, DMD | Mar 22, 2006 8:43:13 AM
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.
Posted by: steve m | Mar 22, 2006 11:32:35 AM
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.
Posted by: | Mar 23, 2006 6:46:48 AM
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.
Posted by: steve m | Mar 23, 2006 7:34:21 AM
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.
Posted by: Larry S. | Mar 23, 2006 1:03:59 PM
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.
Posted by: R. G. | Mar 24, 2006 3:07:30 PM
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.
Posted by: | Mar 24, 2006 4:37:13 PM
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.
Posted by: midwestern surgeon | Mar 25, 2006 5:09:58 PM
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.
Posted by: Gary D. Kitzis, DMD | Mar 28, 2006 11:48:35 AM
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
Posted by: zeinou | Mar 28, 2006 11:01:11 PM
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.
Posted by: | Mar 29, 2006 4:22:29 AM
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.
Posted by: steve m | Mar 29, 2006 11:39:58 AM
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.
Posted by: | Mar 30, 2006 5:34:11 AM
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
Posted by: | Mar 30, 2006 9:42:44 AM
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.
Posted by: steve m | Mar 30, 2006 3:33:45 PM
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.
Posted by: | Mar 31, 2006 3:04:31 AM
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.
Posted by: Peter Gilfedder | Apr 6, 2006 6:42:10 AM
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.
Posted by: David Levitt DDS | Apr 10, 2006 8:34:29 AM
Browse by:
In The News