No Primary Stability with Nobel Replace?

Yesterday I had a patient with failed second molar of right mandible that was extracted one year before.We decided to place a Nobel Replace tapered groovy 4.3 × 10 mm.
First I used the pilot drill 2mm and when I reached the final drill for 4.3 (yellow) I started to insert the implant with the motor at 25 ncm. I had checked the walls of the implant bed and the bottom with a depth indicator and xray. Also I had distance from mandibular canal 2 mm.

However, when I reached at the 2/3 of the height of the implant I felt the implant screwing-falling to the bottom of the bed…like falling when you are in a lift..!
No primary stability!! It was a very big surprise for me since I have experience in oral implantology. But it was my first time using the Nobel System. Usually I use Xive, 3i Biomet and MIS.

I decided not remove the implant and I tried to screw the cover screw and it was screwed with the implant (like the whole system implant-screw was spinning…)
I placed sutures and I pray now for a secondary stability while osseointegration process.

What is your opinion? Did you have any similar cases with the Nobel system?

By the way, I was thinking that the soft bone was the cause, and I had to stop drilling with the 3.5 drill, but the protocol says that the final drill had to be the yellow for a 4.3mm diameter implant in any case of bone, and in case of dense bone to use further tapping drills. Thoughts?

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23 thoughts on “No Primary Stability with Nobel Replace?

  1. That’s going to be a bitch to restore. It appears that you are below the crest of the ridge. Trying to seat an impression post may be very difficult when the time comes. I would go back in and try to bring it more coronally to make your life easier later.

    1. Can’t see a big problem trying to restore that. Probably will integrate if left well alone. Might get some bone growth over the top which may need to be drilled away.

    2. Dear colleague just to be clear with the clinical situation of the placed implant…the implant is at crestal level at buccal side, 0.5 mm subcrestal at mesial side, 1 mm at distal side and 0.5 at lingual side…after evaluate the clinical situation i made a little drilling with a round bur of the distal and lingual bone just to have an easy uncovering of the implant after some months…

      So the restoration is not a problem.

      1. I was referring to all those who have commented on how difficult it will be to restore because of subcrestal placement etc .

    3. If you did not pre-op with a CBCT you may want to get one now.
      Two-dimensional images are not adequate and a post op scan may be able to confirm instead of assuming that you have not perforated the lingual plate.
      You never know if there is an undercut without a scan.

  2. That ‘falling’ in experience makes me wonder if you perhaps perforated the lingual plate? I understand you used a depth gauge probe to feel the floor of your osteotomy; however, were you able to feel the walls of the osteotomy to ensure the were not compromised? Another possibility could be very the quality of the bone and trabeculation . I have often looked at a radiograph and anticipated a normal implant placement when I have almost sinked into the osteotomy from the low bone density. If you leave it to heal with primary healing, for 6 months it may work. I have used Nobel and left ‘spinners’ to heal longer and ultimately restored with great success.

  3. The placement is very good! I wouldnt be so worried about the primary stability since spinners also integrate well! And i know your feeling since I am also using MIS seven and most of the times I get high primary stability, but this is because the protocol of the system is like under prep, and the implant it self is more aggresive compare to nobel replace! If you dont feel very comfortable just wait 4-5 months and thats all! I wish you best of luck and no worries!

  4. You may have benefitted from taking a CBCT prior to implant placement to plan the case. The xray does not give you sufficient information.

  5. i work for implant direct and we sell compatible implant with Nobel Tapered groovy. Replant. Should have stopped at the 3.4 diameter drill. We have crestal bone drills if you find the torque value to be too much at the crest, but with the 3.4 drill in softer bone you should have been fine. Straight osteotomy, tapered implant….compress the bone for stability.

  6. Are you sure you used the right drill sequence/set ? Perhaps you accidentally grabbed ( were handed ) the 5.0 osteotomy drill ( placed in an incorrect sot in the surgical kit box). I have been handed the wrong drill size several times and always double check to be sure it is the correct size before using. Anyway, healing should allow for integration over time.
    ****Take another CBCT to show if the lingual plate was indeed perforated.

  7. I agree that this placement will cause some issues restoring IF it does integrate due to its subcrestal placement and will require modification of the crestal bone to seat restorative components. Also it is possible that you perforated the lingual plate and would manually palpate the area to see if you can feel the implant protruding out the plate. With regards drill sequence one needs to based on the quality of the bone sometimes not use all the drills and use the implant to do the final compaction to get better initial stability. One bases that decision on how the bone feels as you are using the drills. In this case stopping at the 3.5mm drill may have resulted in better initial stability of the placed implant. I would also have if the buccal lingual width allowed it used a wider implant (5.0mm) to #1 get better emergence profile for restoration planned. and #2 better BIC as this implant when restored will be under greater load then teeth mesial to it.

    1. Please, please………follow the manufacturers protocol for implant placement. If you feel uncomfortable with the way the surgery went, then call Nobel directly and ask them for some input. Changing protocols may seem like a good idea ( often in hindsight ) but it can also cause big problems.

  8. I am a long time Nobel Replace user and while I can not speak to the “falling in” element of your situation, it is my experience that spinners integrate fine if left buried to heal for the appropriate time. As per previous posts probably worth checking that there is no lingual perforation.

  9. Give it a try since it is in. Go back to XiVE. It is a unknown, but wonderful implant with great primary stability.

  10. About 35 years ago, I was working with a Calcitek implant in exactly the same area you did, and suddenly when putting the final few twists with 40 Ncm hand force to get the implant down to the crest of the ridge…….. it disappeared!!!!!!!.
    I was sure I was in the inferior dental canal…. just from the xray showing the implant lying horizontal …..in a panic I called Calcitek, and the representative walked me though the solution……
    He directed me “With your fingers, palpate the lingual side of the ridge….. you will feel the implant, and gently massage the implant up the side of the bone…….with a blunt instrument, sever the lingual soft tissue from the bone , and the implant will reappear……. then…… gently put the implant back into the osteotomy, and gently turn it into the final position, without any force………suture the soft tissue….. and leave it six months”…….. that was 35 years ago, the patient is now over 90 and the implant and crown are doing just fine.
    It makes no difference which implant system you use….they all work fine!!

  11. Gentlemen,

    With regard to lingual perforations, has anyone had experience in which a lingual perforation occurred but the soft tissue remained healthy and intact. Can one hope for such an implant to integrate and ultimately become a successful case?

    1. I don’t advise leaving it alone if there is a lingual perforation. The roughness of the implant will be a chronic source of irritation to the patient when he chews, talks, etc. Also a risk of dehiscence of the tissue because of the roughness of the implant and the friction from tongue, eating, etc.

  12. If you want to check have any perforations on lingual or buccal plate, you could use periodontal probe to check after you finish your osteotomy preparation. Find out is there any soft underneath.
    Second, in your case just after remove the tooth, the socket is wider and implant put in is possible has no primary stability even you put bigger size implant like 5.0mm diameter implant. But in my experience, primary stability is not necessary if you do 2stage protocol for implant placement. Wait enough time for Osteointegration like 6 month or more. It will be fine. Don’t worry too much. Good luck.

  13. Hi Guy

    I think that this case has to do with a few key points. I don’t think it is the specific implant system but possibly your level of familiarity with it. More likely though is the bone quality the issue and possibly why there was a previous failure. I think a cbct is essential prior to planning /placement and even do a limited rescan if any chance of a lingual perforation. That way you know what is going on.

    With regard to the previous history of failure and what now seems to be soft bone; I would suggest checking serum vit D levels and LDL. If on the low to lower range of vit D I often add a weekly Calciferol dose and possibly a statin. This is often helpful esp in cases with previous failures or cases with a relevant med history and leave slightly longer to integrate. this helps the biological process and in my experience has been very useful.

    I think with experience we all have cases just like yours. when the bone is soft then stop the drilling one size lower than the final drill or if you worried about cortical compression then use a shorter final diameter drill but to just open the crest.

    Possible someone with osseodensification experience may have some useful thoughts as this maybe very useful in these cases

    good luck

  14. Option 1, Leave it alone…open it up in 4 months, profile the bone, take impression for crown.
    Option2 take cbct
    Option3 envelope flap it on the lingual all the way to tooth 29 to see if u need to remove it, don’t touch the buccal…
    Option 4..go back to option one…

  15. The exact same thing happened to me about a year ago. I was using Replace Select Tapered, although it has nothing to do with the system of implant you are using. On pre-op CT, I could see that there was about 4-5mm of bone at the level of crest as well as decent buccal and lingual bone; however, below the crest, the medullary space was very radioluscent, looking like a sinus cavity. Implant ended up “sinking in” at the last moment when I was trying to get closer to 45NM. Could still visualise it through the osteotomy, but I wasn’t able to retrieve due to spinning. I ended up having to make a buccal window a few mms below my osteotomy, visualize the implant that was hanging through the crest in an empty mudullary cavity and push it up through the osteotomy and grab it with a rongeur.

  16. Same has happened to me using an Implant Direct Legacy 3. I have moved to Dentsply XiVE. Great thread structure. I also have learned at times to stop at “good”. The greatest enemy of good is better.

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