Procedures manual

NobelActive®
TiUltra™

The scope of this surgical procedures manual is toprovide a comprehensive overview of the surgical steps
and options during the placement of NobelActive®
TiUltra™ implants. This surgical procedures manual
does not replace the Instructions For Use (IFU). Please
review the Instructions For Use, including Indications
For Use, Contraindications, Warnings and Cautions
before using the products. Instructions for Use areavailable at:
ifu.nobelbiocare.com
For a full list of article numbers and for ordering
information, refer to the Product overview - Conicalconnection implants and prosthetics available
at nobelbiocare.com or contact a Nobel Biocare
representative.
Note In order to improve readability, Nobel Biocare
does not use ™ or ® in the running text. By doing so,
however, Nobel Biocare does not waive any right to thetrademark or registered mark and nothing herein shallbe construed to the contrary.
Disclaimer Some products may not be regulatory
cleared, released or licensed for sale in all markets.
Please contact the local Nobel Biocare sales office forcurrent product assortment and availability.

Contents
Introduction 5
Quick guide 6
Implant specifications 8
Surgical procedure 11
Important considerations and cautions 12
Surgical access 13
Drill sequence 14
Depth measurement system 16
Screw taps for implant placement in dense bone 17
Flapless procedure 18
Flap procedure 19
Implant insertion 22
Advanced surgical procedures 27
NobelActive TiUltra 3.0 28
Active placement in extraction sockets 30
Stabilization in wide extraction sockets 33
Restorative procedure 35
Important considerations 36
Finalization of implant surgery and temporary restorations 40
Two-stage early/delayed function 41
One-stage Immediate Function procedures 42
PureSet™ 47
Wallchart 48
Appendices 53
Manual Torque Wrench 54
Cleaning and sterilization 56

4

5

Introduction
Quick guide 6
Implant specifications 8

NobelActive® TiUltra™ procedures manual

6

NobelActive® TiUltra™ procedures manual Introduction

Quick guide

Twist Drill with
Tip Ø 2 mm

FlaptechniqueTwist Step DrillØ 2.4/2.8 mm

Twist Step DrillØ 3.2/3.6 mm

Twist Drill with
Tip Ø 2 mm

Flapless
technique
Note The illustrations show the drill sequence forNobelActive TiUltra RP 4.3 in medium bone. For
other implant diameters and bone densities, see drill
protocols on page 14. For specific information
regarding NobelActive TiUltra 3.0, see page 28.

NobelActive® TiUltra™ procedures manual Introduction

One-stage
Immediate Function

Implant
level

One-stage early/
delayed function

Implant
placement
Two-stage early/
delayed function

One-stage
Immediate Function

On1 concept/
Multi-unit Abutment

Abutmentlevel

One-stage early/
delayed function

7

8

Implant
specifications

Implant

NobelActive® TiUltra™ procedures manual Introduction

specifications
Key features‒ Expanding tapered bodyB

‒ Expanding double thread‒ Drilling blades at apex
‒ Internal conical connection (CC)
‒ TiUltra anodized surface

G

F

E
C

D
I
H

A

NobelActive® TiUltra™ procedures manual Introduction

3.0

NP
3.5

A

B

C

D

E

F*

Tip
diameter

CollarheightThreadheightThreadspacing

Threadpitch

Total
length

3.0×10 mm

1.95

0.8

8.7

1.0

2.0

9.5

3.0

2.5

–

3.0×11.5 mm

1.95

0.8

10.2

1.0

2.0

11.0

3.0

2.5

–

3.0×13 mm

1.95

0.8

11.7

1.0

2.0

12.5

3.0

2.5

–

3.0×15 mm

1.95

0.8

13.7

1.0

2.0

14.5

3.0

2.5

–

1.2

2.4

8.0

3.5

3.0

3.5

Platform

3.0
NP
3.5

RP
4.3

RP
5.0

WP
5.5

RP
4.3

RP
5.0

WP
5.5

G

H

I

Major
Abutment Bridge
diameter interface interface

3.5×8.5 mm

2.6

1.0

7.0

3.5×10 mm

2.6

1.0

8.5

1.2

2.4

9.5

3.5

3.0

3.5

3.5×11.5 mm

2.6

1.0

10.0

1.2

2.4

11.0

3.5

3.0

3.5

3.5×13 mm

2.6

1.0

11.5

1.2

2.4

12.5

3.5

3.0

3.5

3.5×15 mm

2.6

1.0

13.5

1.2

2.4

14.5

3.5

3.0

3.5

1.0

16.5

1.2

2.4

17.5

3.5

3.0

3.5

3.5×18 mm

2.6

4.3×8.5 mm

3.2

1.0

7.0

1.2

2.4

8.0

4.3

3.4

3.9

4.3×10 mm

3.2

1.0

8.5

1.2

2.4

9.5

4.3

3.4

3.9

4.3×11.5 mm

3.2

1.0

10.0

1.2

2.4

11.0

4.3

3.4

3.9

4.3×13 mm

3.2

1.0

11.5

1.2

2.4

12.5

4.3

3.4

3.9

4.3×15 mm

3.2

1.0

13.5

1.2

2.4

14.5

4.3

3.4

3.9

4.3×18 mm

3.2

1.0

16.5

1.2

2.4

17.5

4.3

3.4

3.9

5.0×8.5 mm

3.6

1.0

7.0

1.2

2.4

8.0

4.9

3.4

3.9

5.0×10 mm

3.6

1.0

8.5

1.2

2.4

9.5

4.9

3.4

3.9

11.0

4.9

3.4

3.9

5.0×11.5 mm

3.6

1.0

10.0

1.2

2.4

5.0×13 mm

3.6

1.0

11.5

1.2

2.4

12.5

4.9

3.4

3.9

5.0×15 mm

3.6

1.0

13.5

1.2

2.4

14.5

4.9

3.4

3.9

5.0×18 mm

3.6

1.0

16.5

1.2

2.4

17.5

4.9

3.4

3.9

5.5×7 mm

4.0

1.0

5.5

1.2

2.4

6.5

5.5

4.4

5.1

1.2

2.4

8.0

5.5

4.4

5.1

5.5×8.5 mm

4.0

1.0

7.0

5.5×10 mm

4.0

1.0

8.5

1.2

2.4

9.5

5.5

4.4

5.1

5.5×11.5 mm

4.0

1.0

10.0

1.2

2.4

11.0

5.5

4.4

5.1

5.5×13 mm

4.0

1.0

11.5

1.2

2.4

12.5

5.5

4.4

5.1

5.5×15 mm

4.0

1.0

13.5

1.2

2.4

14.5

5.5

4.4

5.1

All measurements in millimeters.
*Please note that actual implant length is 0.5 mm shorter than indicated in name.

9

10

11

Surgicalprocedure
Important considerations and cautions 12
Surgical access 13
Drill sequence 14
Depth measurement system 16
Screw taps for implant placement in dense bone 17
Flapless procedure 18
Flap procedure 19
Implant insertion 22

NobelActive® TiUltra™ procedures manual

12NobelActive® TiUltra™ procedures manual Surgical procedure

Important considerations
and cautions
Implant placement
The unique thread design of NobelActive TiUltra
implants allows to redirect the implant during
insertion. This feature requires special attention to
execute during placement, as the implant will notnecessarily stop at the bottom of the prepared site,
but may go deeper into the bone.
Available abutment margin height needs to beconsidered during the planning of implant placement
to ensure appropriate seating depth of the implant
relative to the available soft tissue thickness and theplanned emergence of the restoration.

Implant insertion with Surgical Driver
If the Surgical Driver (manual hand device) is used
to insert the implant, special attention is required to
avoid overtightening.

Indications and requirements for NobelActive TiUltra 3.0
NobelActive TiUltra 3.0 implants are intended toreplace a lateral incisor in the maxilla and/or a central
or lateral incisor in the mandible. NobelActive TiUltra
3.0 implants are indicated for single-unit restorations only.
Insertion torque for NobelActive TiUltra 3.0
Due to the narrow implant diameter and narrow
implant abutment connection the maximum insertion
torque for NobelActive TiUltra 3.0 differs from theentire NobelActive TiUltra assortment. The maximum
insertion tightening torque for the 3.0 implant is
45 Ncm and the maximum prosthetic abutment
tightening torque is 15 Ncm.
Caution Never exceed insertion tightening torqueof 45 Ncm for the implant and 15 Ncm prosthetic
tightening torque for the abutment screw.
Overtightening of the implant may lead to damageof the implant, fracture or necrosis of the bone site.
Overtightening of the abutment screw may lead toscrew fracture.

NobelActive® TiUltra™ procedures manual Surgical procedure

Surgical accessStandard flap
procedure

Flapless
procedure

Used when it is necessary:

May be used when:‒ to observe the underlying alveolar bone
and adjacent anatomical structures.

‒ there is sufficient quantity and qualityof alveolar bone and soft tissue.

‒ to place bone and/or connective tissue grafts.

‒ it is not necessary to raise a flap to safely direct
drilling procedure in relation to the anatomy.

Tip When using a flapless approach, add soft tissue
height to drill depth.
Warning Besides the mandatory precautions for any
surgery such as asepsis, during drilling in the jaw bone,
one must avoid damage to nerves and vessels byreferring to anatomical knowledge and preoperative
radiographs.

13

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NobelActive® TiUltra™ procedures manual Surgical procedure

sequence
DRILL

Drill sequence

Demonstration of
the drill protocol for aØ 4.3 × 13 mm implantin soft, medium anddense bone.

Soft
bone

Only to widen
cortex

Precision Drill(optional)

Twist DrillØ 2.0

Twist Step
Drill
Ø 2.4/2.8

Twist StepDrill
Ø 2.8/3.2

Implant
4.3 × 13

Precision Drill(optional)

Twist DrillØ 2.0

Twist Step
Drill
Ø 2.4/2.8

Twist StepDrill
Ø 3.2/3.6

Implant
4.3 × 13

Medium
bone

Dense
bone

Only to widen
cortex

Precision Drill(optional)

Twist DrillØ 2.0

Twist Step
Drill
Ø 2.4/2.8

Twist StepDrill
Ø 3.2/3.6

Twist StepDrill
Ø 3.8/4.2

Screw Tap
Ø 4.3
(optional)

Implant
4.3 × 13

NobelActive® TiUltra™ procedures manual Surgical procedure

Platform

Recommended drill sequencebased on bone quality*
During drilling procedures,bone quality should beconsidered. Recommended
drill sequences are basedon bone quality to ensure
optimal primary stability
when applying One-stage
Immeduate Function
procedures. Drills are used to
the full drilling depth.
Drilling must proceed at highspeed (max. 2000 rpm for
Twist Drills and Twist Step
Drills) under constant andprofuse irrigation by sterile
saline at room temperature.

3.0
NP
3.5
RP
4.3
RP
5.0
WP
5.5

Soft Bone
Type IV

Medium Bone
Type II-III

Dense Bone
Type I

1.5

2.0

2.0
2.4/2.8

2.0(2.4/2.8)

2.0
2.4/2.8(2.8/3.2)

2.0
2.4/2.8
2.8/3.2

2.0
2.4/2.8(2.8/3.2)

2.0
2.4/2.8
3.2/3.6

2.0
2.4/2.8
3.2/3.6(3.8/4.2)

2.0
2.4/2.8
3.2/3.6

2.0
2.4/2.8
3.2/3.6
3.8/4.2

2.0
2.4/2.8
3.2/3.6
3.8/4.2(4.2/4.6)

2.0
2.4/2.8
3.2/3.6(3.8/4.2)

2.0
2.4/2.8
3.2/3.6
3.8/4.2
4.2/4.6(4.2/5.0)

2.0
2.4/2.8
3.2/3.6
3.8/4.2
4.2/5.0
Screw Tap

Note All data are stated in millimeters.
Drills within brackets (-) denote widening of the cortex only, not drilling to the full drilling depth.

Preparation of osteotomy

Tips‒ In dense bone situations, drill with
continuous back and forth motion.

‒ Stop drilling if there is no irrigation.

‒ Move the drill up without stopping
the handpiece motor. This allows theirrigation to flush away debris.
‒ Proceed until the desired depth
reference line is reached.
‒ Drills within brackets (-) denote widening of
the cortex only, not drilling to full depth.
Procedure for implant placement in dense bone

‒ In situations where adjacent natural teeth
interfere with the contra-angle head andprevent the drill from reaching the desired
depth, a drill extension shaft may be used.
‒ When using a drill extension shaft, it isimportant to supplement cooling at the
tip of the drill with manual irrigation.
‒ Drills are delivered sterile and are for single
use only. Do not resterilize. Screw taps
are delivered sterile and reusable.

For more detailed information regarding implant
placement in dense bone and NobelActive TiUltrascrew taps, refer to page 17.

* According to classification by Lekholm U, Zarb GA. Patient selection andpreparation. In: Brånemark PI, Zarb GA, Albrektsson T, editors: Tissue-integrated
prostheses: Osseointegration in clinical dentistry. Quintessence, Chicago, 1985,
pp 199-209.

15

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NobelActive® TiUltra™ procedures manual Surgical procedure

Depth measurement system

15 mm

15 mm

13 mm

13 mm

10 mm

10 mm

7 mm

7 mm

0 mm

0 mm

1 mm

The parallel drills have a true depth measurement
system. All drills and components are marked toprepare the site to the correct depth and obtain asecure and predictable position. Drills are available
for implant lengths (laser marks) of 7–10, 7–15 and10–18 mm. The correct diameter and length of thedrills are indicated on the label.
There are no laser marks for 8.5 mm and 11.5 mm
implant lengths. The 8.5 mm is between the 7 mm and
10 mm laser mark. The 11.5 mm is between the 10 mm
and 13 mm laser mark.

Caution Twist Drills and Twist Step Drills extend up
to 1 mm longer than the implant when seated. Allow
for this additional length when drilling near vital
anatomical structures.
Note The marks on Twist Drills and Twist Step Drills
indicate actual millimeter length and correspond to
the implant collar. Final vertical positioning depends
on several parameters, including esthetics, tissue
thickness and available vertical space.

DrillsDrills are made of stainless steel with a diamond-like carbon (DLC) coating, which gives them their black color.
They are used with external irrigation and are available in three lengths: 7–10, 7–15 and 10–18 mm.

NobelActive® TiUltra™ procedures manual Surgical procedure

17

Screw taps for implant
placement in dense bone

15 mm
18 mm

11.5-13 mm

10-15 mm
8.5-18 mm

8.5-18 mm

8.5-15 mm
7-10 mm

3.0

NP
3.5

RP
4.3

Procedure for implant placement in dense bone
If the implant gets stuck during implant installation, or
the maximum torque is achieved before fully seated,
one of the following procedures should be followed:a) Rotate the implant counterclockwise for a few
turns enabling the use of the self-tapping capacityof the implant; orb) back out the implant and widen the site with awider drill according to drill protocol; or

RP
5.0

WP
5.5

c) select a NobelActive TiUltra screw tap whichmatches the diameter of the implant and desired
drilling depth:̵ Place the screw tap into prepared implantsite using low speed (25 rpm).
̵ Apply firm pressure and begin rotating thescrew tap slowly. When the threads engage,
continue to thread the screw tap to the defined
depth without applying additional pressure.
̵ Switch the drill unit with handpiece toreverse mode and back the screw tap out.
d) Continue with implant installation until desired
position is achieved using max 45 Ncm installation
torque for NobelActive TiUltra 3.0 implant or max
70 Ncm for NobelActive TiUltra 3.5, 4.3, 5.0, and
5.5 implants.

18

NobelActive® TiUltra™ procedures manual Surgical procedure

Flapless procedure
Choose between the following two options andcontinue with the drill sequence on page 19,
starting with step 3.

Option A‒ Drill to the appropriate depth using the Twist
Drill with Tip Ø 2 mm. A drill stop can be used.
Maximum speed 2000 rpm
Tip Measure the soft tissue thickness with a probe.
Caution Twist Drills and Twist Step Drills extend up
to 1 mm longer than the implant when seated. Allow
for this additional length when drilling near vital
anatomical structures.
Note The marks on Twist Drills and Twist Step Drills
indicate actual millimeter length and correspond to
the implant collar. Final vertical positioning depends
on several parameters, including esthetics, tissue
thickness and available vertical space.

Option B‒ To facilitate initial soft tissue penetration andcreation of a crestal starting point (also after
flap preparation), the Precision Drill can beused before Twist Drill with Tip Ø 2 mm.
‒ Drill with the Precision Drill through soft
tissue and into the alveolar crest.
Maximum speed 2000 rpm

Ø 2 mm10 mm

NobelActive® TiUltra™ procedures manual Surgical procedure

Flap procedure
The following illustrations show the drill sequence
for NobelActive TiUltra RP 4.3 in medium and densebone. For other implant diameters and bone densities,
see page 15. For specific information regarding
NobelActive TiUltra 3.0, see page 28.

1 Raise a flap
When using a flap procedure, make an incision andraise a flap.

2 Drill with Precision Drill
To facilitate creation of a crestal starting point, thePrecision Drill can be used before Twist Drill with
Tip Ø 2.0mm.
Maximum speed 2000 rpm

3 Drill with Twist Drill with Tip Ø 2 mm
Drill to the appropriate depth using the Twist Drill with
Tip Ø 2 mm. A drill stop can be used.
Maximum speed 2000 rpm

19

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NobelActive® TiUltra™ procedures manual Surgical procedure

4 Check osteotomy direction (optional)
Check correct direction using Direction IndicatorØ 2.0/2.4–2.8 mm.
Tips‒ If applicable, take a radiographto verify correct direction.
‒ When placing multiple implants,
proceed to the next implant site before
continuing to the next drill sequence.

5 Drill with Twist Step Drills‒ Continue site preparation using
Twist Step Drill Ø 2.4/2.8 mm.
‒ Check orientation using Direction IndicatorØ 2.0/2.4-2.8 mm (optional).
‒ Finalize site preparation using Twist
Step Drill Ø 3.2/3.6 mm.
Maximum speed 2000 rpm

6 Determine implant length
Use Depth Probe to verify the desired depth has beenachieved (including soft tissue thickness, if applicable).

NobelActive® TiUltra™ procedures manual Surgical procedure

7 For dense bone only: widen cortex
Widen cortex to full cortex depth using Twist Step DrillØ 3.8/4.2 mm. Do not drill to full drilling depth.
Maximum speed 2000 rpm

8 Use of Screw Tap in dense bone
‒ Place the Screw Tap RP 4.3 into prepared
implant site using low speed (25 rpm).
‒ Apply firm pressure and begin rotating thescrew tap slowly. When the threads engage,
continue to thread the screw tap to the defined
depth without applying additional pressure.
‒ Switch the drill unit with handpiece toreverse mode and back the screw tap out.
Low speed 25 rpm
Note See page 17 for more information regarding
defined depth for NobelActive TiUltra screw taps 3.0,
NP 3.5, RP 4.3, RP 5.0 and WP 5.5.

Special depth marking
for the Screw Tap WP 5.5
11.5–15 mm

21

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NobelActive® TiUltra™ procedures manual Surgical procedure

Implant insertion
1 Unpack implant
Each implant comes in a double sterile solution: theimplant held in an inner titanium vial (a) that is packed
in plastic vial with screw lid, which acts as first sterile
barrier (b). The plastic vial with screw top lid is packed
in a blister sealed with a lid, which is the second
sterile barrier (c). The blister is packed together with
an implant card (d) and patient record labels (e) in a
cardboard box (f).

a) Inner vialb) Plastic vialc) Blister

The cardboard box and the blister have a printed labelwith product data including diameter and length.
The vial is laser marked with implant data including
name, diameter and length (a). The inner titanium vial
cap is color coded to identify the implant diameter.
‒ Open the box and ensure the implant cardand patient record labels are removed.

d) Implant card

‒ Peel off the sealed blister lid in order to open it
and allow the plastic vial on the sterile field.
‒ Unscrew the lid and take out the steriletitanium vial, then lift off the color-coded
cap to gain access to the implant.
‒ Record the implant size and LOT number
on the patient’s profile records with theprovided peel-off labels available in thebox. After surgery, provide the implant card,
completed with the implant information, tothe patient to keep for future reference.
All NobelActive TiUltra implants are delivered withouta cover screw.
e) Patient record labelsf) Cardboard box

The color of the implantvial cap refers to thediameter of the implant.

NobelActive® TiUltra™ procedures manual Surgical procedure

2 Choose insertion instrument
Depending on the clinical situation and accessibility, there arethree different options for implant placement:
Manual placement:a) NobelActive Manual Torque
Wrench Surgicala) with a NobelActive Manual Torque Wrench Surgicalb) with a Surgical Driverb) Surgical Driver

Machined placement:c) with a drilling unit with contra-angle
Tips‒ In the anterior region it is recommended to use
the Surgical Driver to facilitate good control
during insertion and angulation changes.

c) Drilling unit with contra-angle‒ The Surgical Driver is intended to be used while grasped
with fingertips only to avoid excessive insertion torque.
‒ F or NobelActive TiUltra 3.0, the NobelReplace Manual
Torque Wrench Surgical or the Manual Torque Wrench
Prosthetic with Surgical Wrench Adapter can also
be used, as they both have a 45 Ncm marking.

3 Pick up implant‒ Connect the appropriate Implant Driverto the insertion instrument.
‒ Pick up the implant from the inner casing byapplying light pressure on the implant driverand carefully turning the casing counterclockwise until the Implant Driver is fully seated.
a)

Tip The Implant Drivers have markings to facilitate theinsertion of the driver into the implant.

Tip Make sure that the Implant Driver is fully seated.

b)

c)

23

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NobelActive® TiUltra™ procedures manual Surgical procedure

4 Machined implant placement‒ When using a drilling unit, insert the
implant using low speed: max 25 rpm.
‒ Remove Implant Driver with agentle upward motion.
Low speed 25 rpm / Max. torque 70 Ncm

5 Manual implant placementa) Connect the Manual Torque Wrench Adapter
together with the Implant Driver to the NobelActive
Manual Torque Wrench Surgical and place theimplant to final depth.
b) Connect the appropriate Implant Driver to the
Surgical Driver NobelActive and place the implantto final depth.
‒ Remove Implant Driver with an upward motion.
a)Caution Never exceed insertion torque of 45 Ncm
for a NobelActive TiUltra 3.0 implant and 70 Ncm
for NobelActive TiUltra 3.5, 4.3, 5.0 and 5.5 implants.
Overtightening an implant may lead to damage ofthe implant, fracture or necrosis of the bone site. If a
Surgical Driver is used to insert the implant, special
care needs to be taken to avoid overtightening.
For One-stage Immediate Function procedures, theimplant should withstand a final insertion torque of atleast 35 Ncm.
Procedure for implant placement in dense bone
For more detailed information regarding implant
placement in dense bone and NobelActive TiUltrascrew taps, refer to page 17.

Markings for 35 Ncm, 45 Ncm
and 70 Ncm.

b)

NobelActive® TiUltra™ procedures manual Surgical procedure

6 Final implant placement‒ Available abutment margin height needs
to be considered during the planning of
implant placement to ensure appropriateseating depth of the implant relative tothe available soft tissue thickness and theplanned emergence of the restoration.
‒ When placing the implant, align one of the blackhex indicators on the implant driver parallel tothe buccal wall. This ensures that one of the flatsides of the hexagon is parallel to the buccal side,
ensuring preferred prosthetic abutment orientation.

Hex indicators

The Implant Driver has a 3 mm height indicator tofacilitate vertical implant positioning.

3 mm

Hex and heightindicators on
Implant Driver

25

26

27

Advanced surgicalprocedures
NobelActive TiUltra 3.0 28
Active placement in extraction sockets 30
Stabilization in wide extraction sockets 33

NobelActive® TiUltra™ procedures manual

28

NobelActive® TiUltra™ procedures manual Advanced surgical procedures

NobelActive TiUltra 3.0
Indications (specific to NobelActive TiUltra 3.0)
‒ NobelActive TiUltra 3.0 implants are intended
to replace a lateral incisor in the maxilla and/or a central or lateral incisor in the mandible.
‒ NobelActive TiUltra 3.0 implants areindicated for single-unit restorations only.
Contraindications (specific to NobelActive TiUltra 3.0)
‒ NobelActive TiUltra 3.0 implants are not indicatedto be used to replace a central incisor, a canine, apremolar or a molar in the maxilla nor to replacea canine, a premolar or a molar in the mandible.
‒ NobelActive TiUltra 3.0 implants are not indicatedto be used for multiple tooth replacements.

1 Prepare implant site
Prepare the implant site according to drill protocol(see page 14).

2 Pick up implant
Open the implant package and pick up the implantfrom the inner casing with the Implant Driver forNobelActive TiUltra 3.0.

NobelActive® TiUltra™ procedures manual Advanced surgical procedures

3 Final implant placement‒ Insert the implant with low speed, maximum
15 rpm, using drilling machine or by handusing Manual Torque Wrench Surgical.
‒ Due to the narrow implant diameter and narrow
implant abutment connection, the maximum
insertion torque for NobelActive TiUltra 3.0 differsfrom the entire NobelActive TiUltra assortment‒ Place the implant with an insertion torque ofmaximum 45 Ncm (see marking on torque wrench).
For One-stage Immediate Function procedures, aminimum installation torque of 35 Ncm is required.
Tip For NobelActive TiUltra 3.0, the NobelReplace
Manual Torque Wrench Surgical or the Manual Torque
Wrench Prosthetic with Surgical Wrench Adapter canalso be used, as they both have a 45 Ncm marking.

4 Temporary restoration
Depending on the surgical protocol of choice, place acover screw or abutment and suture.
Caution Never exceed insertion tightening torque of15 Ncm for the abutment screw. Overtightening of theabutment screw may lead to screw fracture.
Tip Use the Screwdriver Machine UniGrip and Manual
Torque Wrench.

29

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NobelActive® TiUltra™ procedures manual Advanced surgical procedures

Active placement in
extraction sockets
Achieving esthetic results in the anterior can bechallenging. The buccal bone plate is usually very thinand often missing entirely, and maintaining boneheight and soft tissue architecture requires at least
1.5 mm of bone thickness buccal to the implant.
In order to achieve the desired results, bone augmentation must often be performed prior to implant
placement. In many cases, NobelActive TiUltra
simplifies this procedure.
Caution The unique thread design of NobelActive
TiUltra implants allows to redirect the implant during
insertion. This feature requires special attention to
execute during placement, as the implant will notnecessarily stop at the bottom of the prepared site but
may go deeper into the bone.

1 Create starting point
For creation of a starting point in the palatal wall of
the extraction socket, use the Precision Drill.
Maximum speed 2000 rpm

The tooth is extracted andthe socket is prepared in
the regular manner.

NobelActive® TiUltra™ procedures manual Advanced surgical procedures

2 Prepare implant site‒ F or maxillary anterior teeth, the objective is toutilize bone palatal to the remaining socket in theapical 1/3 to 1/2 for stabilization of the implant. The
palatal wall is first penetrated from a more perpendicular approach to gain a starting point with either
the Precision Drill or the Twist Drill with Tip Ø 2 mm.
‒ C ontinue to drill with the Twist Drill with
Tip Ø 2 mm while gradually changing thedirection to a more vertical direction.
‒ Depending on implant diameter and bonedensity, continue to drill as describedabove, following the drill protocol.
Tip When using a flapless procedure, measure the soft
tissue thickness with a probe. Add this tissue thickness
to the drilling depth for correct site preparation. Be
aware of anatomical landmarks.

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NobelActive® TiUltra™ procedures manual Advanced surgical procedures

3 Implant placement‒ Begin inserting the implant at the same angle as
for the initial drilling. Do not exceed 70 Ncm forNobelActive TiUltra NP, RP and WP and 45 Ncm
for NobelActive TiUltra 3.0 implants.
‒ Continue implant insertion to final position,
while gradually changing the angulation.

Procedure for implant placement in dense bone
If the implant gets stuck during implant installation, or the
maximum torque is achieved before fully seated one of thefollowing procedures should be followed:a) Rotate the implant counterclockwise for a few turns enabling
the use of the self- tapping capacity of the implant; orb) Back out implant and widen the site with a wider drill
according to drill protocol; orc) Select a NobelActive TiUltra screw tap which matches thediameter of the implant and desired drilling depth:‒ Place the screw tap into prepared implantsite using low speed (25 rpm).
‒ Apply firm pressure and begin rotating the screw tap slowly.
When the threads engage, continue to thread the screw tap
to the defined depth without applying additional pressure.
‒ Switch the drill unit with handpiece to reverse
mode and back the screw tap out.

NobelActive® TiUltra™ procedures manual Advanced surgical procedures

Stabilization in wide
extraction sockets
The new Wide Platform (WP) implant is specificallydesigned for posterior cases that require a wider
base. It helps create a natural-looking emergenceprofile for the molar crown, and its shorter implant
body (7 mm) helps to avoid critical anatomical
structures.
Caution Particular caution should be used whenplacing narrow platform implants in the posterior
region due to risk of prosthetic overload.

Procedure for implant placement in extraction sockets‒ Drill apically in the extraction socket, using
Twist Drill with Tip Ø 2 mm or Precision Drill.
‒ Depending on the diameter of the implant
and the bone density, continue site
preparation following the drill protocol.
‒ Start inserting the implant into the underprepared site as described previously.
‒ Bone augmentation may immediately
follow implant placement if indicated.
‒ Place a cover screw and suture.
‒ In the described situation, the One-stage
Immediate Function procedure
approach is not recommended.
Caution Never exceed insertion torque of 45 Ncm
for a NobelActive TiUltra 3.0 implant and 70 Ncm
for NobelActive TiUltra 3.5, 4.3, 5.0 and 5.5 implants.
Overtightening an implant may lead to damage ofthe implant, fracture or necrosis of the bone site. If a
Surgical Driver is used to insert the implant, special
care needs to be taken to avoid over tightening.

Contraindications (specific to NobelActive TiUltra 3.0)
‒ NobelActive TiUltra 3.0 implants are not indicatedto be used to replace a central incisor, a canine, apremolar or a molar in the maxilla nor to replacea canine, a premolar or a molar in the mandible.
‒ NobelActive TiUltra 3.0 implants are not indicatedto be used for multiple tooth replacements

33

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35

Restorative
procedure
Important considerations 36
Finalization of implant surgery and temporary restorations 40
Two-stage early/delayed function 41
One-stage Immediate Function procedures 42

NobelActive® TiUltra™ procedures manual

36

NobelActive® TiUltra™ procedures manual Restorative procedure

Important considerations
Prosthetic interface
Dual-function prosthetic connection: internal conicalconnection for abutments and external platform
for implant-level bridge restorations (NobelProcera
Implant Bridge and GoldAdapt).

Conical seal for abutments

Multiple-unit restorations
When restoring with a NobelProcera Implant Bridge,
or any other full-arch solution, Healing Abutments
Bridge and Impression Copings Bridge must be used
for placement, uncovering and impression taking. The
bridge components ensure soft tissue management
around the prosthetic platform for optimal
prosthetic seating.

Impression coping seating
Proper seating of the impression coping is essential fora correct impression.
To verify that the impression copings are properly
seated, check that the groove on the impression coping
sits correctly at the level of the implant shoulder. Use aperpendicular radiograph if necessary.

Shoulder seating forNobelProcera Implant Bridge

NobelActive® TiUltra™ procedures manual Restorative procedure

Abutment seating
Correct positioning of the abutment is essential for theprosthetic outcome and long-lasting function. Verify
correct vertical abutment seating by using radiographic imaging.
‒ Position the abutment into the implant headand make sure the hexagonal extension engages
properly by gently turning and pushing.
‒ Make sure the abutment feels securely
placed, both horizontally and vertically.
‒ Tighten the screw, but not to full torque.
‒ Take a radiograph to verify properand full abutment seating:̵ No apparent bone interference̵ Alignment of long axes of implant and abutment
̵ No gap in conical interface‒ Space at the bottom of the connection should
appear parallel and measure less than 1 mm.
‒ Tighten the abutment screw to final
torque. Tightening torque for NP, RP and
WP abutments is 35 Ncm, and tightening
torque for 3.0 abutments is 15 Ncm.

Final abutment position withspace less than 1  mm

37

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NobelActive® TiUltra™ procedures manual Restorative procedure

Example 1

Abutment not fully seated due to interfering bone. Long axes are notaligned. Gap in conical interface. Bottom space is not parallel and islarger than 1 mm.

Abutment fully seated. All above parameters are verified.

Example 2

Abutment seems to be aligned with implant but space is larger than 1  mm.

Abutment is fully seated.

NobelActive® TiUltra™ procedures manual Restorative procedure

39

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NobelActive® TiUltra™ procedures manual Restorative procedure

Finalization of implant surgery
and temporary restorations

There are three options for finalizing the implant surgery.

Two-stageearly/delayed
functionOne-stageearly/delayed
functionOne-stage
Immediate
Function

Use Screwdriver UniGrip to connect
a cover screw to the implant.
Suture the tissue flap using thedesired technique.

Place the On1 Base Xeal andconnect the On1 Healing Cap
to it, or connect a healing
abutment directly to the implant.
If applicable, suture back thesoft tissue.

Provisionalize the implant for
immediate esthetics and function,using Nobel Biocare On1 Temporary
Abutments or implant-leveltemporary abutments.

For further information on
this option, please check
On1 concept Quick guide

Tip If the final restoration is an implant-level NobelProcera Implant Bridge, non-engaging Universal Abutment
or non-engaging GoldAdapt Abutment, use a Healing Abutment Bridge to prevent tissue overgrowth on thehorizontal implant platform.

NobelActive® TiUltra™ procedures manual Restorative procedureTwo-stage early/delayed function
1 Uncover the implant‒ Make an incision to expose the cover screwor use the Soft Tissue Punch if there issufficient amount of attached mucosa.
‒ Remove the cover screw using theScrewdriver Manual UniGrip.

2 Remove bone overgrowth
Should bone grow over the cover screw, remove thebone with a rotating instrument and/or a curette. Be
careful not to damage the seating for the Screwdriver
Manual UniGrip.

3 Remove bone around the implant platform with a Bone Mill
‒ After removing the cover screw, remove any bone aroundthe implant platform that will hinder an abutment
being fully seated on the implant platform. This is often
the case when the implant has been placed below
the bone crest. For bone removal, use the Bone Mill
Guide and Bone Mill for the corresponding platform.
‒ The Bone Mill can be handled either manually (with thehandle for machine instruments) or with the drilling unit.

4 Connect healing abutment‒ Connect a suitable healing abutment to theimplant using the Screwdriver Manual UniGrip.
‒ If a flap is prepared, suture back the soft tissue.
Alternative If possible, connect the final abutmentusing the corresponding screwdriver.

41

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NobelActive® TiUltra™ procedures manual Restorative procedureOne-stage Immediate
Function procedures
Implant level,
temporary single-unit restoration
The following illustrations show the use of the
Temporary Snap Abutment Engaging (for single-unit
restorations).

1 Connect abutment to implant‒ Attach the abutment to the implant,
check inter-occlusal space and adjust forheight and clearance if necessary.
‒ Modifications of the abutment can be performed
with a carborundum disk or carbide bur. Extraoral
modification of abutment is recommended.
‒ Place the abutment onto the implant and block
the screw channel. Do not insert the screw: as theabutment is retained by the retention elements.

2 Fabricate the temporary crownwith a TempShell (Option A)‒ Use a TempShell to convert it into an individualized
provisional restoration designed prior to surgery.
‒ Try-in the fit of the temporary crown seating
the wings on the neighboring teeth.
‒ Apply a small amount of acrylic or composite into
the crown and reposition it in the patient’s mouth.
‒ Let the acrylic or composite cureand pick up the restoration.
‒ Finalize the crown – fill the shell with the acrylic/composite, remove the wings and polish therestoration. It is important to have a smoothsurface adjacent to the surrounding soft tissue.
‒ Create the screw access hole using the Apical
Drill and Protection Analog/Drill Guide.
OR

In cases where the implant has reached an insertion
torque of a minimum 35 Ncm it allows the use of
the One-stage Immediate Function procedures totemporarily restore a single-unit restoration with atemporary abutment.

NobelActive® TiUltra™ procedures manual Restorative procedure

2 Fabricate the temporary crownconventionally (Option B)‒ Using the acrylic mold, create the temporary
crown, filling it with dental acrylic or composite
material, and seat it over the temporary abutment.
‒ Follow the material manufacturer’s
instructions regarding curing.
‒ Finalize the restoration following the conventional procedure. It is important to have a smoothsurface adjacent to the surrounding soft tissue.
‒ Create the screw access hole using the Apical
Drill and Protection Analog/Drill Guide.

3 Connect temporary restoration‒ Connect the restoration and tighten it to 35 Ncm
using the clinical screw and Screwdriver UniGrip.
‒ Block the screw access hole using Teflon
tape and close it with composite.
‒ Fill the screw access hole with suitable material.
Caution Never exceed tightening torque for theabutment screw. 15 Ncm for NobelActive TiUltra 3.0, allother CC connections: 35 Ncm. Overtightening of theabutment screw may lead to a screw fracture.

43

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NobelActive® TiUltra™ procedures manual Restorative procedure

Implant level,
temporary multiple-unit restoration
The following illustrations show the use of the
Temporary Abutment Non-Engaging (for multiple
splinted restorations). For individual implants, use
engaging abutments.

1 Connect abutments to implants‒ Attach the abutments onto the implants andadjust for height and clearance if necessary.
‒ Fasten the abutments with guide pinsthat extend beyond the occlusal planewith the Screwdriver Manual UniGrip.
Abutment screw is included with the abutment. The
guide pin (available in two lengths: 20 mm [standard
length] and 30 mm) has to be ordered separately.

2 Fabricate the temporary bridge
using a TempShell (Option A)‒ Use a TempShell to convert it into an individualized
provisional restoration designed prior to surgery.
‒ Try-in the fit of the temporary bridge seating
the wings on the neighboring teeth.
‒ Apply a small amount of acrylic or composite into
the bridge and reposition it in the patient’s mouth.
‒ Let the acrylic or composite cureand pick up the restoration.
‒ Finalize the bridge – fill the shell with the acrylic/composite, remove the wings and polish therestoration. It is important to have a smoothsurface adjacent to the surrounding soft tissue.
‒ Create the screw access hole using the Apical
Drill and Protection Analog/Drill Guide.
OR

In cases where the implants have reached an insertion
torque of minimum 35 Ncm it allows the use of
the One-stage Immediate Function procedures totemporarily restore a multiple-unit restoration withtemporary abutments.

NobelActive® TiUltra™ procedures manual Restorative procedure

2 Fabricate the temporary bridge using theconventional procedure (Option B)‒ Fabricate the template from acrylic orcomposite for chairside ­temporization.
‒ Make access holes to allow guide pins to protrude.
‒ If the laboratory has made a prefabricatedprovisional bridge, make access holes to allow
the guide pins to protrude (if not alreadydone) and adjust it to the abutments.
‒ Fill template with acrylic or composite andseat it over the temporary abutments.

3 Adjust temporary restoration‒ After seating, loosen the guide pins
to remove the restoration.
‒ Trim and polish the restoration. It is
important to have a smooth surface
adjacent to the surrounding soft tissue.

4 Connect temporary restoration‒ Connect the provisional restoration withthe supplied abutment screws.
‒ Tighten to 35 Ncm using Manual Torque Wrench
Prosthetic and Screwdriver Machine UniGrip.
‒ Fill the screw access holes with suitable material.
Caution Never exceed tightening torque for theabutment screw. 15 Ncm for NobelActive TiUltra 3.0,
all other CC connections: 35 Ncm. Overtightening maylead to a screw fracture.

35 Ncm

45

46

47

PureSet™
Wallchart 48

NobelActive® TiUltra™ procedures manualWallchart

10-18 mm
Ø 2.4/2.8 (#3) 32262
Ø 2.8/3.2 (#4) 34639
Ø 3.2/3.6 (#5) 32265
Ø 3.8/4.2 (#6) 32277
Ø 4.2/4.6 (#7) 34583

7–15 mm
Ø 2.4/2.8 (#3) 32261
Ø 2.8/3.2 (#4) 34638
Ø 3.2/3.6 (#5) 32264
Ø 3.8/4.2 (#6) 32276
Ø 4.2/4.6 (#7) 34582
Ø 4.2/5.0 (#8) 37876

Twist Step Drills
7–10 mm
Ø 2.4/2.8 (#3) 32260
Ø 2.8/3.2 (#4) 37873
Ø 4.2/4.6 (#7) 37874
Ø 4.2/5.0 (#8) 37875

Twist Drills
Ø 1.5 (7–15) 31278
Ø 2.0(7–10) 32296
Ø 2.0 (7–15) 32297
Ø 2.0(10 –18) 32299

NobelActive® TiUltra™ procedures manual PureSet™

Screwdriver
manual UniGrip 28 mm
29149*

Direction Indicator
32112

48

Depth Probe 7-18 mm
37791

Precision Drill
36118

Bone Mill (with Guide) CC
3.0 Ø4.0 37861
NP Ø4.4 37863
NP Ø5.2 37864
RP Ø5.2 37866
RP Ø6.2 37867
WP Ø6.7 37869

Bone Mill Guide CC
3.0 37862
NP 37865
RP 37868
WP 37870

NobelActive®/
NobelParallel™ CC
PureSet™ Tray
PUR0200

49

Surgical Driver
32180

Drill Extension Shaft
29164

NobelActive® TiUltra™ procedures manual PureSet™

NobelActive Manual Torque
Wrench Surgical
34584

Screw Tap
3.0 36816
NP 3.5 36236
RP 4.3 36237
RP 5.0 36238
WP 5.5 (7-10) 37871
WP 5.5 (11.5-15) 37872

Implant Driver WP
28 mm 37859
37 mm 37860

Implant Driver RP
28 mm 36720
37 mm 36721

Implant Driver NP
28 mm 36718
37 mm 36719

Implant Driver 3.0
28 mm 36773
37 mm 36774* Available in other lengths

50NobelActive® TiUltra™ procedures manual PureSet™

NobelActive® PureSet™

87294(The articles below can also be purchased individually)
NobelActive /NobelParallel CC PureSet Tray

PUR0200

Surgical Driver

32180

Implant Driver CC 3.0 28 mm

36773

Implant Driver CC 3.0 37 mm

36774

Implant Driver CC NP 28 mm

36718

Implant Driver CC NP 37 mm

36719

Implant Driver CC RP 28 mm

36720

Implant Driver CC RP 37 mm

36720

Implant Driver CC WP 28 mm

37859

Implant Driver CC WP 37 mm

37860

Screwdriver Manual UniGrip 28 mm

29149

Drill Extension Shaft

29164

Direction Indicator Ø2 / Ø2.4-2.8 mm (4x)32112

Implant/Prosthetic Organizer

29532

NobelActive® Manual Torque Wrench Surgical

34584

Depth Probe 7-18 mm Z-shaped

37791

Implant Sleeve Holder

29543

NobelActive Radiographic Template

37887

NobelActive / NobelParallel CC PureSet Wall Chart

300565Note Drills and Screw Taps are available for separatepurchase and are not included in the kit.

Bone Mill with Guide Conical Connection(To be accommodated in the PureSet™)
Bone Mill with Guide Conical Connection 3.0 Ø4.0

37861

Bone Mill with Guide Conical Connection NP Ø4.4

37863

Bone Mill with Guide Conical Connection NP Ø5.2

37864

Bone Mill with Guide Conical Connection RP Ø5.2

37866

Bone Mill with Guide Conical Connection RP Ø6.2

37867

Bone Mill with Guide Conical Connection WP Ø6.7

37869

For more information regarding the product portfolio
see the ‘Product Overview - Conical Connection
Implants & Prosthetics’.

52

53

Appendices
Manual Torque Wrench 54
Cleaning and sterilization 56

NobelActive® TiUltra™ procedures manual

54

NobelActive® TiUltra™ procedures manual Appendices

Manual Torque Wrench
For the surgeon, the torque required to place implants
provides insight into the primary stability of theimplant. For restorative procedures, tightening theabutment and prosthetic screws to the recommended
torque specifications will more effectively control
screw-joint integrity during patient function.
The Manual Torque Wrench is a convenient tool forachieving the desired torque.

Manual Torque Wrench – Surgical
Intended for tightening or adjusting implant position.
‒ Indicating torque values 45 Ncm and 70 Ncm‒ Insert Implant Driver Conical Connection

Manual Torque Wrench – Prosthetic
Intended for tightening or adjusting abutment or
screw position.
‒ Indicating torque values 15 Ncm and 35 Ncm‒ Compatible with all machine screwdrivers‒ Insert the applicable driver

NobelActive® TiUltra™ procedures manual Appendices

Use of the Manual Torque Wrench Surgical‒ Select the corresponding Manual Torque
Wrench Adapter Surgical and insert the corresponding Implant Driver into the adapter.
‒ To tighten an implant, adjust the direction
indicator so that the arrow is pointing toward
the level arm and rotate clockwise.
‒ To loosen an implant, adjust the direction
indicator so that the arrow is pointing away fromthe level arm, and rotate counterclockwise.
Warning If force is applied to the main body of theManual Torque Wrench Surgical and not to the leverarm, the applied torque cannot be measured. High
forces may cause over compression of the bone leading
to bone resorption, especially in case of a thin buccal/
lingual marginal bone crest.
After use, disassemble the Manual Torque Wrench by
removing the adapter and the rod from the wrenchbody. Please follow the steps described in the IFU for
Manual Torque Wrenches Surgical and Prosthetic.

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NobelActive® TiUltra™ procedures manual Appendices

Cleaning and sterilization
Sterile components

Refer to the Instructions For Use (IFU1076) for
NobelActive TiUltra for detailed cleaning and sterilization instructions.
ifu.nobelbiocare.com
Note Implants must never be resterilized or reused.

Implants
Implants are delivered sterile, are for single use only,
and must be used prior to the labeled expiration date.
Warning Do not use device if the packaging has beendamaged or previously opened.
Caution NobelActive TiUltra implants are single use
product and must not be reprocessed. Reprocessing
could cause loss of mechanical, chemical and / orbiological characteristics. Re-use could cause crosscontamination

Twist and Twist Step Drills, Precision
Drill and Screw Taps
Twist Drills and Twist Step Drills are delivered sterileand for single use only. Screw Taps are delivered sterile
and reusable.

NobelActive® TiUltra™ procedures manual AppendicesNon-sterile components

Caution Care and maintenance of instruments
are crucial for a successful treatment. Sterilized
instruments not only safeguard your patients andstaff against infection but are also essential for theoutcome of the total treatment.
Refer to the Instructions For Use (IFU1067) for PureSetfor detailed cleaning and sterilization instructions.
ifu.nobelbiocare.com

Abutments and plastic copings
Refer to the Instructions For Use (IFU1093) for theabutment or coping for detailed cleaning and sterilization instructions.
ifu.nobelbiocare.com
Notes‒ If modifications have been made to the abutment,
clean the abutment prior to sterilization.
‒ Non-sterile plastic copings should not be resterilized, as they are for single use only.

57

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NobelActive® TiUltra™ procedures manual AppendicesNobelActive® TiUltra™ procedures manual Appendices59Order online
Order our complete range of
implants and prefabricatedprosthetics 24 hours a day throughthe Nobel Biocare online store.
nobelbiocare.com/store

Order by phone
Call our customer service team orcontact your sales representative.
nobelbiocare.com/contact

Lifetime warranty
The warranty covers all Nobel
Biocare implants including prefabricated prosthetic components.
nobelbiocare.com/warranty

nobelbiocare.com/nobelactive
87722 GB 2110 Printed in the EU © Nobel Biocare Services AG, 2021. All rights reserved. Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothingelse is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbiocare.com/trademarks for more information. Productimages are not necessarily to scale. All product images are for illustration purposes only and may not be an exact representation of the product. Disclaimer: Some
products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability.
For prescription use only. Caution: Federal (United States) law restricts this device to sale by or on the order of a licensed clinician, medical professional or physician. See
Instructions For Use for full prescribing information, including indications, contraindications, warnings and precautions.