Ensuring Dental Implant Success

Dr. Jeffery Hoos is well known for developing the ‘H&H’ impression technique for crown and bridge impressions. He is also very experienced in placing and restoring implants and presents two-day hands-on courses across the country on several implant systems. Dr. Hoos is also a management consultant and is well known for his seminars on ‘Balancing the Art, Science and Business of Dentistry’. Dr. Hoos maintains a general practice in Stratford, Connecticut. Many of his patients come from out of state or out of the country.

Osseonews (ON): Dr. Hoos, could you describe how you and your hygiene staff maintain the implant cases you have placed and restored?

Dr. Hoos: The patient has a tremendous investment in time and money when it comes to large implant cases and what surprises all of us is how dirty their mouths are sometimes after such extensive treatment. A patient taught me an interesting lesson by the following response to my surprise about their lack of oral hygiene. “Doc, how do you think I lost my teeth?” So the most important aspect of our hygiene staff in “Patient Motivation”.

ON: What kinds of problems or complications do you see after the prosthesis has been delivered, the implants restored and the patient has been in function for several years?

Dr. Hoos: The biggest complication I have seen over the years is breakage and wearing out of acrylic restorations. Remember most of the large cases were restored with denture teeth with acrylic on metal frameworks. These wear out and in our great haste and excitement, I am not sure we explained or prepared the patient for the upgrades and remakes. “Doc, I thought this would last for years.”

ON: Do you routinely make a nightguard for your implant patients to wear at night after the case has been delivered?

Dr. Hoos: This really depends upon the case but I have learned the hard way, because the parafunctional habits of some of these patient will break and loosen anything. So I use an NTI appliance to stop them from grinding. If you use a full coverage splint the patient will grind that and transfer the forces to the implants even though that force is distributed evenly.

ON: How do you evaluate teeth adjacent to implant sites that have had previous endodontic treatment?

Dr. Hoos: If I see an old root canal fill with a radiolucent lesion, I either retreat the endontic therapy or extract the tooth. I have also had unexplained implant failures next to endodontically treated teeth with no pathologic signs or symptoms. I think this is one area in treatment planning that has to be very thoroughly investigated prior to placing any implants.

ON: If a tooth adjacent to the implant site had prior root canal treatment but has a persistent radiolucent lesion that has been there several years and has not increased in size, the tooth is asymptomatic and the soft tissue is normal, would you place an implant in that site under those conditions?

Dr. Hoos: No. I would either retreat or extract.

ON: How do you adjust the occlusion of single implant crowns?

Dr. Hoos: This is a very interesting question and difficult to answer. I keep them out of occlusion when a normal biting force is exerted but in occlusion in forced hard closure. How do I know this? It is a balancing act and having said that, of course no balancing side contacts. I use a device called a T Scan to measure the loads of the teeth around the implant and make sure I am getting what articulating paper and shim stock is showing me. It can be tedious but very important to avoid future complications.

ON: How much interarch space do you feel is necessary to make a maxillary bar retained overdenture, measuring from the implant platform to the opposing occlusion?

Dr. Hoos: I want as much as I can get because it eliminates breakage problems. I also always have a metal frame in the overdenture surrounding the bar for strength. This is why the denture must be completed up to the wax-try in phase to evaluate where the implants should be placed and how much room is available in the interarch distance. Planning, planning, planning for these cases is the key and because we all want to get the implant in because of the healing phase. I will never do an overdenture implant case without first doing a temporary denture first. I have made that mistake only once.

ON: What attachment system do you prefer for overdentures?

Dr. Hoos: I want to use a system that is easy to change when the nylon sleeves wear. ERA’s by Sterngold are good but require a lot of room. The Locator is also a nice attachment and requires less room for placement.