The Dentist vs. Implant Tissue Showdown: Just How Lucky Do You Feel?



You’ve got an implant patient in your chair, and the first thing you’re thinking, “Do I feel lucky?” Well, do you, implant dentist? Does the patient present with all the required soft tissue health characteristics for successful implant treatment, or don’t they? Considering that the patient's prior periodontal history and willingness to maintain superb oral hygiene habits are the most powerful determinants of success—or could blow your case out of the water—you make a bet and hope your pick lands on the wheel of luck.

In any case, you surrender to the fact that thorough soft tissue risk assessment and evaluation are significant to implant success and must be addressed before spinning the wheel and undertaking any procedures. If patients have or had advanced periodontitis, that—combined with poor hygiene—makes it a sure bet that they are not good candidates for implant treatment. And if patients express a desire to modify their poor oral hygiene habits, the smart wager is waiting some time to allow them to demonstrate a serious commitment, because those habits absolutely correlate to long-term implant success.

Of course, there are other tells—such as smoking and uncontrolled diabetes—that could suggest the deck is stacked against long-term implant success. However, those are actually indicators, as opposed to direct causes, of implant periodontal problems. So to up the odds in you and your patient’s favor, consider what makes for a safer bet (meaning, low risk) and one where the stakes are higher (meaning, high risk).

Low risk implant patients have a healthy medical status, low esthetic expectations, and are non-smokers. They present with a low lip line, low scallop/thick biotype, and rectangular shape. The treatment site has no history of prior infection, intact soft tissue anatomy, and no deficient bone. The bone level of adjacent teeth is less than 5 mm to contact; adjacent restorative status is virgin; and the width of span is ≥ 7 mm.

Note that a thick tissue phenotype is found in more than two-thirds of patients. They are predominantly men with quadratic tooth anatomy, a broad zone of keratinized gingiva, and flat gingival contours.

High risk implant patients, on the other hand, have a reduced immune competence, high esthetic expectations, and are heavy smokers (i.e., more than 10 per day). They present with a high lip line, high scalloped/thin biotype, and triangular shape. The treatment site has acute infection, soft tissue defects, and vertical bone deficiency. Additionally, adjacent teeth are restored, with a bone level of 7 mm to contact, and the width of span is 2 or more teeth.

Here, bear in mind that less than one-third of patients—predominately women with slender tooth anatomy and a narrow zone of keratinized tissue with high scalloping—present with a thin phenotype. Also, an estimated 11% of bicuspids, 24% of cuspids, 23% of lateral incisors, and 7% of central incisors are surrounded by thin phenotype tissue. Remember too, that patients can have a thin phenotype but still have substantial bone (i.e., quantity and quality) underneath.

Not assessing periodontal tissues and a patient’s risk factors is essentially testing their luck and your chances for achieving predictable outcomes. Fortunately, when tissue augmentation is necessary, current trends in soft tissue management demonstrate that subepithelial connective tissue grafts are the gold standard when a coronally advanced flap is created and acellular dermal graft, enamel matrix derivative, or collagen matrix is placed. The riskier proposition is placing a free gingival graft, which has been shown to disappear from the esthetic zone and is very limited, even in esthetically irrelevant applications, unless the graft is de-epithelialized.

Another way to hedge your bet? Use healing abutments with the proper size, shape, and handling characteristics. Anatomic healing abutments protect soft and hard tissues and reduce crestal-bone resorption compared to concave/straight healing abutments. The expert technicians at MicroDental Laboratories can assist with the design and use of these essential implant treatment components.


Jerry Hu, DDS, Dr. Jerry Hu is triple board certified in dental sleep medicine and holds masterships, fellowships, and accreditations in implant and cosmetic dentistry. He also has published numerous clinical studies in peer reviewed, highly respected journals such as AACD's Journal of Cosmetic Dentistry, and AADSM's Journal of Dental Sleep Medicine. Dr. Hu also teaches for Modern Dental Group both nationally and internationally, and for Sleep Group Solutions, VIVOS growth guidance appliance group, and Prosomnus Sleep Technologies. He also has won numerous awards in cosmetic and implant dentistry from Macstudio Model Search by MicroDental, and IAPA Aesthetic Eye competition. He is currently working on a patent for dental sleep medicine, and looking to help the US military out in dental sleep medicine.

Better Case Acceptance with F.A.B.



Getting patients to ‘YES’ is a challenge, sometimes because we are so forward with telling them what they ‘NEED’ instead of waiting until they ‘WANT’. One technique I have personally used and coached hundreds of others with remarkable success is, to “play hard to get”. Let me explain. If we remain patient and refrain from telling them the answer, the path is easier. By asking questions about what they see or think about the problem we engage their curiosity and co-discovery. These are natural tendencies in patients that are often squelched by our well-intentioned urge to tell them what they need right away. Talk about the problem, ask them questions, show them images using the intra-oral camera and hold off moving to the solutions discussion until they…wait for it…ASK YOU what you think. If we stay in the question with them, they will eventually ask us what we think they should do. Their curiosity gets the best of them and they truly want to know. That is when I play hard to get.

After successfully engaging them about the image of a failing MODBL, showing them the open margins, describing the decay process, asking about percentages of tooth versus material and advising them about the inevitability of this tooth needing a root canal if left untreated, they succumb to their curiosity and ask the inevitable question, “what do you recommend?” This is where it gets fun. Instead of simply answering them, I put on my sales and marketing hat and FAB (features, advantages and benefits) the crown they need. Marketing 101 reminds us to never sell the thing, rather sell the Features, Advantages and Benefits of the thing.

I explain that there are several different clinically acceptable ways to fix that tooth, but I need some information from them to make the recommendation. First, would they prefer a solution/material that will last several years or one that with some luck, might even last the rest of their life? Most folks go for longevity. Then I ask if they prefer the material we use to be tooth colored, silver or gold metal? Most choose the esthetic alternative. Without ever saying they NEED a crown, I simply asked them what features, advantages and benefits they WANT! This improves the odds of completing their treatment significantly, but not to 100%.

One more crown per week or bite splint, or periodontal treatment or implant etc. can have a significant impact on production. Just think, at $1,200 per unit, and 50 weeks you would increase production $60,000 and help fill your schedule. The same can be said for chair time in hygiene as well. No communication skill, script or technique is foolproof, but by shifting the odds in our favor we will get more yesses, fill our schedule and help patients have healthier mouths.

Are You a Jedi, or Are You Causing a Disturbance in the Force?



Unless you’ve lived under a rock—and not one on the planet Tatooine—you know the cinemagraphic tales of the Jedi and their quest to preserve peace in the universe. The success of their mission, like the success of implant treatments, hinges on balance in the Force. A Jedi harnesses the Force for knowledge and defense, but never for attack. Unfortunately, when factors affecting implant success aren’t properly considered, the Dark Side could basically destroy the overall treatment. Put another way, the Dark Side is the potential for Force imbalances to cause peri-implant bone loss and implant prosthesis failure.

So what is the Force we’re talking about? According to Merriam-Webster, force can be defined as (1) strength or energy exerted or brought to bear that causes motion or change; (2) an agent or influence that, if applied to something, leads to its acceleration or deformation; or (3) any natural influence that exists that determines the structure of the universe. There are nine forces that influence implant success or failure and that dentists must consider during treatment planning. These include apical, lingual, distal, mesio-distal, occlusal, facial, facio-lingual, mesial, and vertical axis forces. If there is a disturbance in any of these, the dental implants could be prone to occlusal overload.

The good news is that you can be a Jedi and apply knowledge of these forces to defend your treatments against the consequences of the Dark Side. Implant force disturbances can occur due to problems with large cantilevers, patients with parafunctional habits/ bruxism, occlusal interferences, and/or poor-quality bone. Limited contacts result in poor force distribution, and steep cusp inclines and increased cusp height equate to bone loss. Just like a Jedi must exercise control to better harness the power of the Force, so too must dentists take into consideration and control variables like these that affect implant occlusion in order to ensure long-term treatment success.

This means managing Force in the best ways possible; in other words, establishing protected implant occlusion, and much of that depends on implant placement and prosthetic design. Among the recommendations for achieving the best protected implant occlusion are ensuring straight and centered axial occlusal force load; a narrow occlusal table; and reduced cusp inclination, which concentrates forces over the central fossa. The Jedi implant dentist keeps in mind that ideal occlusal centric contacts are loaded as much as possible on the central fossa, avoiding the marginal ridge.

And remember, too, that the balance you’re seeking is all about how everything in the implant-restoration complex works together—like ideal occlusal timing and an increased implant surface area, which decreases stress (also known as the Dark Side of the Force). Depending on the case, you may need to create long contact areas by using wider implants and/or splinting implants, which also helps to decrease marginal bone loss, abutment screw loosening, and porcelain and component fracture. Or, you might need to reduce the length of cantilevers or the crown-implant ratio, or decrease anterior guidance, especially since a 10-degree increase causes a 30% increase in loading of the prosthesis and/or implant. If you don’t prevent disturbances in these forces, the stress will impact the abutment and implant neck, causing screw loosening, fatigue fracture, and destruction.

The bottom line: Balance in the Force is never by chance. When everything works together, that’s when peace and balance in the universe of your implant treatment occurs. And that’s why it’s essential to communicate with your MicroDental Laboratory technician throughout the implant treatment planning process. Through collaboration, components of the implant-restoration complex can be properly designed to ensure protected occlusion, an ideal crown-implant ratio, and that lateral and sheer forces are avoided.


Jerry Hu, DDS, Dr. Jerry Hu is triple board certified in dental sleep medicine and holds masterships, fellowships, and accreditations in implant and cosmetic dentistry. He also has published numerous clinical studies in peer reviewed, highly respected journals such as AACD's Journal of Cosmetic Dentistry, and AADSM's Journal of Dental Sleep Medicine. Dr. Hu also teaches for Modern Dental Group both nationally and internationally, and for Sleep Group Solutions, VIVOS growth guidance appliance group, and Prosomnus Sleep Technologies. He also has won numerous awards in cosmetic and implant dentistry from Macstudio Model Search by MicroDental, and IAPA Aesthetic Eye competition. He is currently working on a patent for dental sleep medicine, and looking to help the US military out in dental sleep medicine.

Improving Case Acceptance; The Patient's Journey


By Dr. Mark Murphy, DDS, FAGD

Helping patients have healthier mouths, doing more of the dentistry that is fulfilling and making more money as a result, are admirable goals that most practices have.  I have written a couple times about techniques that help us improve case acceptance; creating curiosity and co-discovery, listening, the learning ladder and more.  This brief construct is an attempt to see the process as a journey for the patient and to take their perspective.

Patient’s Journey; Eighteen Inches at a Time

I sat in church a few months ago and listened to an excellent sermon on faith.  It would apply to any religion, but my mind drifted to the ‘Business Case’ this construct offered for dentistry.  As Father Mike spoke about a faith journey, I envisioned parallels in dentistry with case acceptance.  I kept out a keen eye for a bolt of lightning.

It Starts in the Head

Patients first listen to the facts about dental care, their need and wants, issues or diseases that they have and potential treatment solutions.  Sadly, facts are not enough.  We all acknowledge that developing great listening skills, caring and trust help patients come to see you as their health advisor. This requires an eighteen-inch Journey to the Heart! It is there that caring and trust live. The emotional connection is very important in case acceptance and to ignore it, is to minimize your success. But that too is not enough.

The patient must schedule, keep appointments and pay for the recommended treatment. This Journey to the Wallet is the next eighteen-inch trip the patient must take.  It is the execution of the plan from their perspective.  Valuing dental care and oral health are demonstrated by their checkbook and what they spend time and money on.  Still not done?

The next eighteen-inches take us to a knee.  Appreciation helps fulfill us as caregivers.  Most rewards are best when they are balanced, financial and behavioral, money and warm fuzzies, you get the idea.  Money alone does not buy happiness (but it does help you enjoy your misery in some mighty fine places!) This is when I really kept guard for that bolt of lightning for drifting from the faith focus of the story.  I prayed for forgiveness as I created this metaphor and took out my phone to type some notes.

The final journey takes us eighteen inches to the patient’s feet.  Like a missionary, when patients tell others about your practice and refer their friends, you have come full circle.  This trust display is the ultimate compliment to you and your team.


Keep the Patient’s Perspective in Mind

Ask yourself the following and seek answers with your team to enhance patient’s health, your fulfillment and rewards.

·         Have you helped nurture the movement to the heart?

·         Did the patients accept and schedule treatment?  If not, why not?

·         Were they able to pay with gratitude and appreciation? (borrowed from Dr. Pankey)

·         Did you ask for and receive referrals of their friends and family?

Remember, it is a journey not a destination.  Enjoy the trip and check the map along the way. You, your team and your patients will all be the better for it.


“A Journey is best measured in friends, rather than miles.”

Tim Cahill

Not All Steaks Taste the Same!

Best in town.jpg

By Dr. Mark Murphy, DDS, FAGD

There are several reasons that you can buy filet mignon at your grocery store or butcher for anywhere from $10.99-$25.00 per pound.  Forget the fact that Authentic Japanese Wagyu Filets will set you back $214.50 per pound, and that’s at Costco! One reason is the cost they paid and profit margin they add, the other is the grade of the beef.  Good, Better and Best cuts of meat, each have a different price when you go shopping.

The same can be said for the impression materials, composites, and other dental supplies you use every day.  There are quality differences that sometime create huge variances in performance. The raw materials used for ceramic or metal frames, copings and finished restorations made for you at Modern and MicroDental Laboratories have the same scope of quality available.  If you start with a USDA Select or Choice Steak and try to serve it at Morton’s for $45, your customers will not come back.  The quality will not match the price.  Conversely, if you start with USDA Prime, dry aged and sell it for $19, you will go broke. 

ZirCAD Pucks.jpg

The good news is the difference between Good, Better and Best Zirconia is not 2-3X.  For the small incremental cost of using the best Zirconia available like the Ivoclar materials that Modern and MicroDental use, you get a better, more esthetic and predictable restorative solution.  Cheaper Zirconia will not look or perform as well.  There is a difference in the final product when you start with a lower quality raw material.  The purity, how the pucks are pressed, and the performance characteristics can produce a wide variance that will compromise your patient care.  The race to the bottom for the cheapest monolithic Zirconia Crown carries a huge price tag.  Just like cheaper cuts of meat that will be tough to chew, the customer/patient will be disappointed.

We are proud to use the best materials available. 

The new Ivoclar eMax ZirCad raises the bar even further. It has all the quality characteristics as their other raw Zirconia solution plus incredible esthetics.  It’s the first time you have seen them put the eMax brand name onto a Zr material.  We do buy in volume and pass the savings on to you.

The next revolution in strong aesthetic restorative materials is here, you are going to love it!

People eating steak.jpeg

“Good, better, best. Never let it rest. ‘Til your good is better and your better is best.” St. Jerome

A winning smile!


We love how the World Cup unites cultures from around the world and gives us all something to smile about. Yones is ready to let the games begin with his energetic smile, dentistry by Dr. Alex Naini of Aesthetic Dental Spa in Vienna, VA. Macstudio restorations by MicroDental Laboratories. See more winning smiles at