Posted July 10, 2015
I had the absolute honor (and well, terror), to do an implant on #8 on my long term mentor, friend and absolute idol, Dr Gerald Niznick. If you are into implants and have not been sleeping under a rock for the past 30 years, you may know about him. He holds hundreds of patents in implantology and implant restorative solutions. His two big claims to fame are INVENTING the internal connection in root form implants and bringing implants to the masses, including us general dentists. Doing an implant on #8 on this man would be the equivalent of doing a single central on Frank Spear. So yeah, I was a bit nervous. But you know, you have to inform the patient of the risks and benefits of implantology. Since the Doc is now retired and on a fixed income, I suggested a bridge or flipper as low cost alternatives, but ultimately convinced him of the benefits of an endosseos implant :). (For those of you who are a little slow on the uptake, thats a joke, Dr Niznick sold a portion of Implant Direct for just under $400 Million!) Note the consent form signed under protest!! #8 has a vertical root fracture on the buccal and has an abscess, so the plan is for extraction, CEREC Guide, placement of a 4.7 by 16mm HA coated Legacy 4 (The Doc’s request), grafting with DFDA cadaver bone and a collagen membrane, then temporization with a stock Zirconia abutment. So lets get busy!
#8 was removed atraumatically, it may be hard to see, but we have a deep long vertical crack as well as resorption on the palatal. Yes there is a buccal abscess. I was a little leery about placing the implant, but the Doc was confident in his immune system, plus we got out all the soft tissue and put him on Ab, so I am sure it will turn out fine.
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Got the tooth sized up for a CEREC Guide using the Small reference body. Also scanned him up in CEREC for the SSI file and planned on using the Smile Design feature to get the lip line in there.
Now any anterior case I do I use Smile Design. They say if you tell a patient something before you do it, its information. If you tell them after, its an excuse! So I want my patients to know what their final restoration will look like before we place the implant. By marking these points we can then superimpose the face in 3D over our model and evaluate the lip. If you have been to one of my lectures you know that there are 3 variables to a good anterior implant crown: being 3-4mm apical to the proposed CEJ, but no greater than 5mm apical to the contact, and how the lip drapes. I have a lot of F-ugly crowns out there that I got saved by a low lip line.
Whats almost as good as having Dr Niznick hang out in the office? Virtual Dr Niznick! We can see in the 2D shot we have a nice low lip line, and we can evaluate the angulation and display from the sides in the 3D view! How cool is that?
While this was going on, my assistant was helping me construct the Radiographic Guide and I then combined the SSI and Galileos scans and kicked it back to CEREC as a .cmg/dxd. Love that Mach 2 material for the model.
So the Doc and I had a difference of opinion. I like my implant platform to be a little palatal, so I have the option of a screw retained crown. He had enough bone buco-lingually so I felt good about the more buccal aspect of my implant apex. The Doc wanted a 4.7 by 16, I would have preferred a 4.2. Also he wanted to use a stock abutment and was OK with even an angled abutment to maximize the buccal thickness of bone. He also wanted HA. So, the customer is always right, so we went with his plan, although maybe not as buccal as he wanted.
Placed the guide and started with the 2.3mm pilot. I always place the drill into the osteotomy and not only take a radiograph, but evaluate the angulation. I liked my placement, but the Doc felt I was too palatal.
My placement was on the left, the drill shows where the abutment screw would eventually go. The Doc wanted me to lean more buccal so I removed the guide and free handed the drill and redirected it with more of a buccal tip. Dr Niznick took great glee in watching me chuck the guide and do it “old school”. But again, who am I to argue with the guy who was doing implants when I was in elementary school.
I just love the look of an HA coated implant!! Nice and long for stability, we got about 60 Ncm of torque. The Doc wanted 80 but I was not in love with how the implant was directing as we really undersized the osteotomy so I drilled a bit more mesially.
Dr Niznick was happy with the stock abutment that comes with the Legacy 4, it does have a nice platform switch, but I really wanted to make the temp in CEREC, so we tried a few things. The Doc thought that an 8 degree taper would better place the abutment in a more restorable position, but it was too far palatal. So we ended up just using a stock, straight Zirconia abutment and did not have to touch it!!! Both on margins and occlusal reduction. Like that never happens!!
Some other views of the abutments in the mouth. Again, no prepping on Zirconia= Happy August!
Safety First!! We used a DEKA laser to expose the cord prior to CEREC scanning. To be honest we were just too sub gingival. If we used a scan post and a ti base we could have nailed it, but Dr Niznick really wanted to use a stock abutment, so I ended up just aborting the CEREC scan and making a bisacrylic temp. We were planning of flapping, but wanted to make the temp first to avoid heme issues.
Sorry for the bloody shots (brrrr hate blood), note the defect, just did a sulcular incision and reflected back. Placed DFDBA from Direct Gen and a Cytoplast collagen membrane. Sutured with gut and cemented the temp. Yes the tissue looks beat up, it was leaking pus a few hours before and was a bit boggy. Dr Niznick is getting his crowns redone by a Pros friend so if those papilla don’t grown back he can always drop the contact points. Whew! Still mentally drained from yesterday! But quite an education and honor to work on the man that really propelled my career and has helps thousands of patients and dentists worldwide! I’ll post the restorative shots later.
Here is the final, we did get a little recession on the distal, but based on Doc Niznick’s smile line he shouldn’t show it. This case was restored by Dr. Guiarmo Roman, a pros friend of Dr Niznicks!
