Nobel Replace Select Implants Broke at Crest: Best Options?

I suggest removal. You can try flapping and backing out with lower extraction forceps, trephining etc. this is not a good situation for perio hygiene or restoration.

It is "flowered" and won't be able to hold an abutment. I set my implant drill to 20 ncm but is 40 ncm indicated for Nobel? Can't you just back it out by using a ronguers on the abutment? Can the neobiotech remover work on a flowered implant? I had a similar situation and called Nobel they were no help at all.

You know this is a shame, the implant is lined up perfectly. Perhaps backing it out and tapping it when the bone is dense. It is a sinking feeling when this happens, I've had this happen with Straumann implants, the locking up not flowering.

Ask your Nobel dealer for the Nobel implant retrieval tool (product ref 36139). He must give it to you for free understanding the situation (regardless of that it cost me +/- 35€ + VAT or so). It's very easy and simple to retrieve in this early stage. I would understand the fracture if a high torque was applied. I would be pissed if it fractured just like in the situation you described. But oh well... that is implant dentistry.

What you see is an untoward event as a result of both implant design and material. Like most European companies, they use commercially pure titanium (CP-4). This is ostensibly because of some early studies showing a slight change in cellular activity when alloy is used (reaction to aluminum or vanadium). Problem is, an implant fracture is surely of greater consequence than a slight change in cell metabolism. We stopped using these old architectures not just because of implant body fracture, but also because of deformation or fracture of abutments. Then, even if you have a well integrated implant, we tend to see unacceptable crestal bone remodeling in this design. Maybe this is why Nobel just recently changed their abutment connection. But...surprise! There are reports of the same type of peri-implant problems with this "new" connection. So I guess we can fall back on an old axiom..."you can put lipstick on a pig.......". RJM

Usual fracture for this type of Implant but think not due to Ti type more abutment ( Driver ) connection , the tri-lobe as a natural weak point especially on the 3.5 . The lobe must be buccal if a"flat " section is buccally placed it can fracture between the lobes . Strange this case not sure the true picture is being related as curious as to why the abutment is placed etc . Anyway easy to remove with the Neobiotech system and place another with care and ensure the protocol is followed as to lobe position. Peter

You can use the Nobel extraction system to extract it and re-do the case..

Bob, thanks for the information. During my early days, I had a patient present with a flowered CoreVent basket implant , site #18 . This too, was a CP Ti implant.

I have a really dumb question, if the implant was not fully seated did it lock up during insertion? If so why not just back it out, would the Nobel insertion tool (or Neobiotech tool) seat deeper into the implant past the break and allow removal ? I reread the Nobel manual and it allows for up to 45ncm before " compressing the bone and negatively affecting the internal connection" is that company terms for breaking the implant? And I find the discussion on the pure titanium and strength very enlightening. I had to remove so few implants usually very mobile and don't have much experience with this. And Peter I did not know the reason for the lobe position to prevent fracture vs a prosthetic reason. I think this is misleading by Nobel and I thank you and Dr Hughes for the valuable insight.

Newbie question here , is the purpose of an implant lobe being buccal simply for lab technician to know that several adjacent implants are impressed correctly ? Does it matter for a single unit? I don't quite understand the logic of one lobe to buccal. A bit off topic but would appreciate the feedback.

Hi CRS we have been making our Implants (Intoss) since 1986 and have tried to understand bio-mechanical forces in the management of stresses . The Tri lobe was a route around the internal Hex patent issue I presume but there may be this strength issue if protocol is not closely followed. We did not have the issue as Barry invented the internal hex thus was using it prior to the patent which is now elapsed. I have not had a single Implant fracture although have had 2 hex fractures when used with cantilever prostheses. Peter

If your torque is not at right angles to the trilobe (meaning your driver is tilted even just a little, you are not properly engaging the hex and you are applying a shearing force to this tiny little structure. It's bound to break. NP replace is a horrible connection. I went through this learning curve 8 years ago. Never again. Remove this ASAP. Doesn't it seem a bit odd that Nobel has an implant retrieval tool? It's almost as though they knew this would occur. Plus you've got a tapered implant with huge aggressive threads in the mandible. Recipe for high insertion forces. Did you tap the prep? You can screw in an impression coping to make it easier to remove.

AB OMA, it is odd that a manufacturer would have a retreival tool. CRS thank you. I do not know what I said that was so insightful. If its about the broken implant that I left in the ladies mouth, let me know. This was a situation where she presented with a broken implant and it was far easier on her to leave it and place an implant at 19 and move on. Common sense approach. She had a CoreVent Basket design implant made of CP Ti. She had a bite force like a hippopotamus.

Removing the implant with a trephine damages the bone and after that you may not be able to put the implant immediately. Just because the implant fractured, you have to follow a long treatment plan as you need to do bone grafting or whatever required, leave it for 8 months and then redo the implant. I think its better to read the manufacturer's guidelines properly, again and again and also following them properly to avoid these kinds of accidents. Best of luck.........

I am strongly against using a Trephine as it will destroy all the bone as bone must be already very thin as NP implant is being used Try to remove the implant after three week of this eposode, You will be able to remove it by attaching the impression post or abutment to the implant and using an extraction forceps. Allow the socket to heal for 3 months before reinserting.

Too bad some of the posters feel the need to get into implant company bashing...how is this going to help the poster of this case?? This same situation happened to me ONCE...I used the implant retrieval tool and it worked beautifully...I was able to place a second implant immediately. Btw, I wonder why in this case you were not able to seat the fixture to the full depth of the osteotomy? Good luck...and my suggestion to some of the above Dr's is that they also immediately discard their crown removal instruments... DrT

The connection of the Nobel Replace was originally designed to "get around" the patent for the connection developed by Dr Axel Kirsch and his team. This is the connection that has been in Camlog implants and is well proven. A part of the reason for the weakened wall in Replace designs is that the contact angle of the connection is oblique, so producing a more unstable connection (with greater rotational discrepancy) and a more "explosive" force. On those rare occasions when there is a fracture in the Camlog design, it is the cams of the insertion tool which fracture, not the implant. These cams are at 90 degrees to the grooves which produces less rotational discrepancy and less explosive force. In terms of the removal of an implant removing a buccal window should be considered. This need only be of the width of the implant. When this is taken out, the implant can be malleted out from the lingual. This leaves a defect where it is possible to place another implant immediately and to replace or regenerate the missing buccal wall. This is nicely documented by Prof Gert de Lange on the CamlogConnect.com website, of which I am the Editor.

I'm a prosthodontist but my surgeons have had several 3.5mm replace selects fracture like this. The wall is quite thin between the trilobe and outer part of the implant creating a weak area. My surgeons feel that these implants tend to fracture in denser bone. The standard protocol is to undersize the osteotomy, then the tapered design expands the bone increasing initial stability. If the implant "wedges" into the osteotomy and insertion torque continues to be applied the thin walls can break and the implant effectively is wedged into the bone. This is why it is so difficult to back out. I have never seen this happen in the maxilla, only in the mandible. If you look at the radiograph, the size of the remaining osteotomy is quite small in comparison to the diameter of the implant. I may respectfully suggest to my surgical colleagues that if the bone is type I or II, prepping the bone more closely to the diameter of the implant may help decrease the insertion torque placed on the implant. Since this is not an immediate load implant, insertion torque of 20Ncm +/- should be sufficient and will keep this from happening again. Also, Dr. Hughes, I was thinking that all corevent implants were a titanium alloy (hence the Niznick v Branemark bruhahas in the early years over whether CP titanium was mandatory for integration). I have had several small diameter corevent internal hex implants flower on me too, primarily in the molar regions after several years of function.

These are fun! I have had it happen twice. The first time (discontinued Imtec) was one of the first implants I placed (an implant overdenture case). When it fractured I excused myself from the operatory, went into my office, changed my underwear, and then loaded the patient into my car and drove him across town to an oral surgeon with a good sense of humor. I watched over his shoulder as he used a long narrow diameter diamond to make some space on the mesial and distal to about 1/2 the length of the implant. That relieved some tension on the implant, and he was then able to counter-rotate it with orthodontic wire twisting pliers that he stocks specifically for that purpose. The patient, who remains a practice favorite, returned a week later and allowed me to place a new implant at a different site. The second time it happened I sighed and shook my head, followed the lesson taught me and then immediately placed a wider diameter implant at the same site. The patient is unaware that any event occurred. Other than the implant failure, it appears that your treatment plan and execution were sound. The angulation is perfect and the length of the osteotomy was appropriate to protect the mental nerve. The failure is the result of excessive torque. If you find torque increasing during a future case, the appropriate action is to back the fixture out, increase the diameter of the osteotomy and then re-insert the same implant. Trephine burs remove significantly more bone than a narrow diamond and seem inappropriate in this circumstance.

Remove it and put in another implant asap...... more carefully though. Make the osteotomy big enough and if in screwing in the fixture, you are reaching 40ncm, back out, enlarge and try again. To remove it first, grab hold of your trusty extraction forceps or angled orthodontic pliers, hold on tightly and unscrew it or jiggle it out.... something like removing a broken root. Try using a periotome or if you don't want to spoil it, use a couplands on it. If all this does not work, send the patient home and see again in a week. The usual necrotic margin that develops around a new implant will allow removal quite easily then. Remember to give the patient a chlorohexidine mouth wash to use daily until removal.

I have used the neobiotech kit, the kit from Bti (both costing $$$). Neither works as well as the nobel implant removal tool mentioned above. You can use a thin (*.3mm) cut off disk to shorten it to get more bite on the implant if it does not engage. (this changes the end diameter and that changes the engagement). The groove/thread pattern on the nobel tool is a thin, narrowly spaced thread with fine grooves. They really work. First experience with it was removing a 6 x 16 tapered nobel. After trying both the neo-biotech and the Bti kit with no success. I used it today to remove a frozen healing abutment. The straumann scs driver stripped when trying to remove the healing abutment, hence the need to use this tool. I was able to remove the frozen (not cross threaded) healing cap after drilling a hole in the top of the healing abutment to make space to engage the tool. The cost for the nobel part is about 50-60$, Nobel implant retrieval tool ((product ref 36139)) I consider it one of the best values in implant dentistry. Get one and some cut off disks to have on hand. You will be glad you have them and at minimal cost. ***You need the gold adapter for your nobel ratchet to use the tool.***