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IMPLANT
&
Q A:
An Interview with Dr. Gerald Niznick Interview of Gerald A. Niznick, DMD, MSD by Managing Editor David Casper
Dr. Gerald Niznick, a prosthodontist, implantologist, avid researcher and innovator, shares his thoughts on the evolution of implant dentistry. He also discusses how he began placing implants, his multimillion-dollar research study with the U.S. Department of Veterans Affairs, implant design, and the process of building his own implant companies.
David Casper: Thanks for being here
today, Jerry. Gerald Niznick: Thanks for having me,
Dave. DC: You began in private practice as
a prosthodontist in the late ‘60s and started working with dental implants in 1971. Tell us about that journey. What made you decide to work with implants? GN: After graduating with a master’s
degree in prosthodontics at Indiana University, I opened a dental office in San Fernando Valley, California, and was the only prosthodontist out of 1,000 dentists in the area. Those other dentists sent me their denture patients. At that time, there was no good solution for a loose lower denture. So I got involved with the American Academy of Implant Dentistry. I placed the types
of implants that were available back then: blade, subperiosteal, and some screw-type implants. By the end of the ‘70s, I was somewhat disenchanted with their low level of predictability and thought that there must be a better solution. DC: Were you primarily doing lower
overdenture retention cases? GN: I was doing three-unit bridges,
subperiosteals, and fully edentulous cases — rather extensive surgery. But it really didn’t stabilize the lower denture. By the end of the ‘70s, I started thinking of ways to solve that problem. If I could save two or three teeth, I could stabilize that lower denture. I said, “There must be a way to do that with dental implants.” The Core-Vent implant and the overdenture attachment emerged from that idea.
– Implant Q&A: An Interview with Dr. Gerald Niznick –
DC: You wrote a paper on that in 1982. It was the first time someone published an article about using freestanding implants to support an overdenture attachment. GN: Yes, it was probably the first
documented case ever done with freestanding implants. In order to achieve osseointegration with freestanding implants, I had to develop a special set of surgical protocols. I had to avoid overheating the bone, get good initial stability, and then leave the implant unloaded for a period of three or four months. If I did all of those steps right, the implant osseointegrated. DC: That same year, you also founded
Core-Vent. That was also when the first Toronto Osseointegration Conference was held. Was that just purely coincidental? How did those three things come together at the same time?
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GN: Fortunately for me, they did.
GN: Yes. Every Monday afternoon, I’d
After I started with Core-Vent, a friend of mine told me about Per-Ingvar Brånemark’s work in Sweden. I went to a library at USC and found a book on the Brånemark System. I was very pleased to see that somebody had done long-term follow-up studies on implants that had osseointegrated. The studies didn’t test different implant designs or materials; all they showed was that if you could get an implant to osseointegrate and stay there for a year, it would stay there for at least 10 years. So I started lecturing on Brånemark’s research in association with the Core-Vent implant.
place implants, and every Tuesday, I’d lecture.
I attribute the commercial success of Core-Vent to marketing education. I was marketing continuing education instead of the implant. I ran two-day courses every week at my office and trained thousands of dentists that way. I traveled and lectured all over the world. Core-Vent became the largest implant company in the world by 1990. DC: So you were still a practicing prosthodontist at the time?
I attribute the commercial success of Core-Vent to marketing education. I was marketing continuing education instead of the implant. 12
DC: Research is also a component of education. Around the same time the internal hex innovation materialized, the FDA was considering changing the classification of dental implants to a Class III device, which would have classified them like pharmaceuticals. So all of the major implant companies at the time were embarking on pretty aggressive research and development studies to prepare for the pending classification change. You took the biggest swing of all with the U.S. Department of Veterans Affairs (VA) study, which included 32 centers and 1,000 different patients. Why take such a big bite? What was the objective there? GN: We had to go big, because at that
point, we had four different implants, and there was a rumor that the FDA was going to require a different study for each quadrant of the mouth or for each application. Therefore, we had to devise a study that was allinclusive. It became very expansive. I had committed over 4 million dollars to the study, and the VA matched that amount. Nearly 1,000 veterans were treated with implants, and the results were published in two special issues of the Journal of Oral and Maxillofacial Surgery and a special issue of the Journal of Periodontology, documenting both the success of the implants and the bone loss that occurred. The biggest thing that came out of that was the understanding that the bone loss associated with an endosseous implant is related to how thick the labial plate is during implant placement. There was a direct correlation. DC: What about implant surface? What were the surface technologies like at the time? Were there any conclusions made from the study? GN: Initially, implant surfaces were
like orthopedic hips. The Core-Vent system was made by blasting the implant surface with aluminum oxide,
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Dr.Niznick receiving honorary doctorage degree from the University of Manitoba.
then treating it with an acid wash to get rid of the aluminum oxide particles. The problem with using aluminum oxide is that you need to use acid to get it off, and that blasting-andetching process smooths and rounds out the threads and the cutting edge of the self-tapping grooves. By 1986, competitors such as Nobel Biocare were selling implants with machined surfaces. That implant surface is not popular today because it’s too smooth. They started looking at our surface with aluminum oxide and found some aluminum particles still remained. Then, I switched to a hydrofluoricacid-etched surface, which created micro pits. It worked nicely on pure titanium, but it was too smooth. By 1991, I had switched to blasting the implants with hydroxyapatite in a process I called “soluble blast media,” which is similar to resorbable blast media or microtextured surfaces. You end up with a medium-textured surface without any contamination, thus retaining the sharpness of the threads. And that is what we’ve used since 1990. DC: How long did you keep practicing
before you had to focus on the implant company full-time?
GN: By 1986, I was pretty much done
practicing. A few associates lined up patients for me, and I would walk in and do that surgery because the cases helped in the training programs. By 1987, I had stopped that. I was too busy, the company was growing, and I traveled a lot. DC: That must’ve been a lot of work. Over 35 patents have been issued to you in the field of dental implantology. The one that gets talked about the most is what was originally referred to as the internal hex. How did you come up with that idea? What impact has that had on the field? GN:
The Core-Vent implant was developed with a hex hole. From my experience with post and core, I could put a variety of abutments in it. So I developed the hex hole for screwing the implant in and then a variety of abutments that could be cemented on top. The implant system I created provided prosthetic versatility via application-specific prosthetic components, whereas the Brånemark System® implant (Nobel Biocare; Yorba Linda, Calif.) had one multi-unit abutment and didn’t allow for angled abutments or optimal esthetics. From my experience with crown & bridge dentistry and creating chamfer
margins, I came up with the idea to make a lead-in bevel to the internal hex for lateral stability, and I reduced the marginal gap. That has become the modern conical connection. Most companies make an implant with dimensions comparable to the original 1986 Screw-Vent® implant (Zimmer Dental; Carlsbad, Calif.), including Zimmer (who bought Core-Vent in 2000), BioHorizons, and Inclusive. Those brands were smart enough to copy that connection exactly. There is a company that has cloned that connection in just about every country. DC: There also seems to be a clinical benefit to an internal connection versus an external hex when it comes to screw loosening. Why is that? GN: Originally, people said, “An inter-
nal connection is just an implant with an external connection turned upside down.” But that totally discounts the biomechanics behind the internal hex. When you have an external hex implant, you can’t make the hex very high because it would interfere with angled abutments, and lateral forces would cause the screw to flex because it would be tipping off of the shoulder. That leads to screw loosening. So the key was, if we could eliminate screw loosening with a better connection, we could then do cemented restorations on these implants and get away from the screw-retained restorations with their access hole coming through the crown. So really, the internal connection made conventional implant prosthodontics possible. DC: You mentioned earlier that you sold
your company in 2001 to what is now known as Zimmer. What made you decide to get back into the implant game in 2006 with the launch of Implant Direct? GN:
Dr.Niznick receiving the Isaiah Lew Memorial Research award from the American Academy of Implant Dentistry.
I leased my 40,000-squarefoot implant factory in Calabasas, California, to Zimmer as part of the change-of-ownership transaction, but that lease expired in October 2004. Zimmer informed me in early 2004 that they were not going to renew the lease. They were building their own
– Implant Q&A: An Interview with Dr. Gerald Niznick –
I saw a niche between the discounter and the premium companies. manufacturing plant in Carlsbad, so I was going to be left with an empty building and about 100 employees who really knew how to make implants and weren’t going to move to Carlsbad. I was under a five-year non-compete agreement, but that did not restrict me from preparing to compete. In June of 2004, I opened an office across the street from my old factory and started interviewing employees and buying equipment. When they moved out, I dropped 12 machines on the floor the next day. DC: But did the world really need an-
other implant company in 2006? GN: Well, based on how fast Implant
Direct has grown, that appears to be the case. I identified a niche. There were premium-priced companies that just kept raising their prices every year, without really changing the product or providing more benefits to their customers. Then there were discounters that did not have the capital to build broad implant systems. They didn’t have the knowledge to be innovators either, so I saw a niche between the discounter and the premium companies. I created what I call the “value segment” of the market, which includes broad product lines, all-inone packaging, system compatibility, and an emphasis on online education and customer service. Implant Direct launched in October 2006, and it’s been a straight upshot from there. The big implant companies have been feel-
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ing the squeeze from what I created. My company is still in the midsection and represents value because I’ve continued to innovate products and stay ahead of the curve. DC: It was one of the first dental implant
companies in the Internet space. How did that change your business model? GN: Well, the implant world was not
well represented on the Internet, and I figured I could market against the big companies. I wasn’t going to provide the same level of education as I did with Core-Vent, or what Nobel Biocare and Straumann were doing. DC: You didn’t have any sales represen-
tatives to start out? GN: We didn’t. We went after the
low-hanging fruit. We said: “You want to take a course? Take it from Nobel, Straumann or Zimmer, and come and buy implants from us. We have a compatible implant.” We grew and gained a critical mass to the point where income was flowing into the company, but I realized that if I really wanted to be a major player, I needed an outside sales force to convince specialists to buy from us. Today, Implant Direct has about 80 outside sales people, plus the same number of inside tech support and customer service people. DC: Implant Direct started with Spectra-
System® (Implant Direct; Las Vegas, Nev.), and it seems like that’s a continuation from the original Core-Vent implant, which had application-specific abutments. The Spectra-System seems to feature application-specific implants as well. Was that also a coincidence, or just an evolution in your mind? GN: That was precisely my strategy. If
I can give a dentist different implants, all with exactly the same body but with different platforms for different applications, I thought that would dramatically simplify the process for dentists. They could follow one surgical protocol with applicationspecific implants. If you know what your application is, buy the implant
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for that purpose. That was the idea we launched with. DC: You’ve never been one to shy away
from controversy in all the years we’ve known each other. So let’s talk about guided surgery. What’s your opinion on it? GN: I don’t think guided surgery is
controversial. Back in the ‘80s, I’d lay a flap and figure out what to do, move the bone around, and place six implants. But now I see people place six implants with a surgical guide in half an hour. If I was doing surgery, that’s how I’d want to do it. I think surgical guides may be overused for single-tooth implant placement. I certainly think that doing a CT scan, whether you’re going to use a guide or not, is an advantage for treatment planning and choosing which implant diameter and length you’ll need.
three-piece transfer that I developed is available for the Legacy™4 implant and the InterActive™ implant (Implant Direct). You have the abutment, which we’re able to make longer now, and you don’t have to cut it off to get the straight abutment; you can either leave that abutment in the implant and use it for temporaries, or you can take it out and put it into an implant analog and pop it into the impression. If you choose to leave it in the implant, then we have abutment analogs, so you put the abutment analog in the impression, and you have an abutment-level transfer. I think providing that straight abutment with the most accurate metal-to-metal contact transfer is probably the last good idea I’m going to have. DC: I don’t think that will be the case.
Thanks for being here today. I really appreciate it. GN: Thank you, Dave. IM
DC: One of the side benefits of doing
guided surgery is the ability for early or immediate provisionalization. What’s your opinion on immediate loading and immediate provisionalization? GN: Immediate loading has proven to
be successful if you get enough initial stability. You can stop at an intermediate drill if the bone is soft, screw in a self-tapping implant, and compress the bone, which has been shown to increase the percentage of bone contact. You end up with a high level of stability, even in soft bone. DC: Well, as we sit here today,
you’re six months postretirement. You decided to leave the business at the end of 2013. What would you say is your final or most significant innovation right before you left the business?
WATCH THE VIDEO
GN: The last innovation,
with a patent pending now, is a three-piece fixture mount. There’s always a debate over whether or not an open-tray impression is more accurate than a closed-tray impression. The
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