Principles, concepts, and practices in prosthodontics - 1 9 9 4

Academy of Prosthodontics

PREFACE TO THE EIGHTH EDITION Kurth, S. Howard Payne, Chester K. Perry, Richard
This edition is the latest of a continuing effort by the Kingery, Victor L. Steffel, A r t h u r E. Aull, 0. C. Applegate,
Academy of Prosthodontics to u p d a t e the principles, con- Davis Henderson, Henry E. Ebel, I. Kenneth Adisman,
cepts, and practices in prosthodontics. Charles Bolender, Jack Preston, Louis Boucher, Francis V.
The seventh edition was a substantive u p d a t e with the Panno, A r t h u r O. Rahn, George E. Smutko, Ned B. Van
addition of statements and revision of some of the existing Roekel, and Dale E. Smith.
statements. I n p u t for the seventh edition came from the Members of the Principles, Concepts and Practices
A c a d e m y of Prosthodontics, American A c a d e m y of Fixed Committee for the eighth edition were Drs. Ronald H,
Prosthodontics, American Academy of Esthetic Dentistry, Jarvis, Chairman; Dorsey J. Moore, and Aaron H. Fenton.
American Academy of I m p l a n t Dentistry, American Acad- Drs. Noel D. Wilkie, Richard J. Grisius, Edwin J. Riley, and
emy of Maxillofacial Prosthetics, American Academy of Gerald M. Barrack were consultants to the committee.
Periodontology, American College of Prosthodontists, the RESPECTFULLY SUBMITTED BY:
Midwest Academy of Prosthodontics, Northeastern Gna- DR. RONALD H. JARVIS, CHAIRMAN
thological Society, Northeastern Prosthodontic Society, PRINCIPLES, CONCEPTS, AND PRACTICES COMMITTEE:
and the Pacific Coast Society of Prosthodontics. DORSEY J. MOORE, AARON H. FENTON
All organizations t h a t participated in the revision were PRINCIPLES, CONCEPTS, AND
asked for their editorial input in this revision. Some orga- PRACTICES IN PROSTHODONTICS-1994
nizations, such as the Academy of Prosthodontics, sought
input from each member; others worked by committee. Guide to P C P statements
Definitions 73
Each contributing organization funded its own committee
Diagnosis and treatment planning 74
activities. Because the last revision was a major overhaul of Prognosis 75
the document in content and format, this revision has been Prerestorative treatment 75
limited to primarily editorial changes. The Academy of Treatment of oral structures 75
Prosthodontics is indebted to Mrs. J u d i t h A. Farer, a pro- Reevaluation and refinement of treatment plan 76
Prosthodontic treatment 76
fessional editorial consultant, for her work in editing this
I. Basic to most areas of prosthodontics 76
document. II. Fixed partial dentures 79
The Academy of Prosthodontics wishes to thank all of III. Removable partial dentures 81
the participating organizations for their input. The section IV. Maxillofacial prosthetics 85
on Legal Considerations was developed and revised by Dr. V. Complete dentures 87
VI. Implant restorations 90
Burton R. Pollack, who is an attorney and dentist and Dean
Materials and devices 91
of the School of Dental Medicine, State University of New I. Articulators 91
York, Stony Brook, New York. Interim restorations 92
The purposes of the Principles, Concepts, and Practices Auxiliary personnel and work authorization 92
in Prosthodontics--1994 are: Legal considerations 92
1. To provide a reference for the practicing prosthodontist and DEFINITIONS S
general dentist of principles, concepts, and practices that are
currently accepted by leading prosthodontists. 1. Prosthodontics is the branch of dentistry pertaining to the
2. To assist predoctoral and postdoctoral students of prostho- restoration and maintenance of oral function, comfort, appear-
dontics, particularly the graduate student, in assessing the ance, and health of the patient by the restoration of natural teeth
value of various ideas that are presented during their educa- and/or the replacement of missing teeth and contiguous oral and
tional experience. maxillofacial tissues with artificial substitutes.
The first study 1 was prepared in 1957 under the leader- 2. Fixed prosthodontics is the branch of prosthodontics con-
ship of Drs. Luzerne G. Jordan, F r a n k M. Lott, and Rus- cerned with the replacement and/or restoration of teeth by artifi-
cial substitutes that are not removable from the mouth.
sell W. Tench. The six successive publications 27 were pre-
3. Removable prosthodontics is the branch of prosthodontics
pared under the auspices of fellows of the Academy: Drs. concerned with the replacement of teeth and contiguous structures
George Hughes, 0. M. Dresen, Victor H. Sears, Leroy E. for edentulous or partially edentulous patients by artificial sub-
stitutes that are removable from the mouth.
4. Maxillofacial prosthetics is the branch of prosthodontics
concerned with the restoration and/or replacement of stomatog-
J PROSTHETDENT 1995;73:73-94. nathic and associated facial structures by artificial substitutes that
Copyright | 1995 by The Editorial Council of THE JOURNALOF may or may not be removable.
PROSTHETIC DENTISTRY. 5. Implant prosthodontics is the phase of dentistry concerning
0022-3913/95/$3.00 + 0. 10/8/59402 the restorative phase following implant placement.

JANUARY 1995 THE JOURNALOF PROSTHETICDENTISTRY 73

T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
DIAGNOSIS AND TREATMENT
PLANNING
A. Gathering information f o r a d i a g n o s i s
1. Diagnosis is a scientific evaluation of existing conditions.
2. At the first appointment, the patient should be encouraged
to describe previous medical and dental experiences. The dentist
must be attentive and record the patient's concerns and expecta-
tions.
3. A list of questions about prior dental experience may guide
the patient to provide information not otherwise elicited in an
open-ended discussion.
4. A diagnosis may require information from one or more of the
following sources: medical and dental histories, a clinical exami-
nation, radiographic surveys, diagnostic casts, consultations with
other health practitioners.
5. Tests, pretreatment procedures such as a diagnostic pros-
thesis, trial prosthesis, and surgery may yield additional informa-
tion.
6. The patient should be considered a potential carrier of con-
tagious disease. The dentist should follow current guidelines of the
American Dental Association (ADA), the U.S. Centers for Disease
Control and the Occupational Safety and Health Association
(OSHA) during patient care.
7. Correctly mounted diagnostic casts are usually necessary for
diagnosis and treatment planning.
B. Examination
1. A standardized examination form may be used to record data
during the examination.
2. The oral cavity, visible pharynx, paraoral structures, and as-
sociated lymph nodes should be examined. Patients with special
needs may require additional diagnostic procedures such as speech
analysis, psychosocial assessment, occlusal analysis, diagnostic
sounding procedures, sialography, photographs, and other testing
mechanisms.
3. All patients with natural teeth should receive a thorough,
systematic periodontal examination including a clinical and ra-
diographic examination, pocket depth probing, and an evaluation
of periodontal status.
4. The dentist should identify and record any active disease
process and any defects created by disease. When indicated, the
dentist should refer the patient to appropriate professionals for
further diagnosis or treatment.
5. Assessment of the following conditions is essential to the pe-
riodontal examination:
(a) Gross periodontal pathosis including evaluation of topog-
raphy of the gingiva and related structures
(b) The existence and degree of gingival inflammation
(c) Periodontal pocket depth to determine the attachment
level and to provide information on the health of the sub-
gingival area
(d) Presence and distribution of bacterial plaque and calcu-
lus
(e) Degree of tooth mobility
(f) An adequate number of diagnostic quality radiographs
(g) Documentation of loss of attached gingiva
6. Exploratory surgical procedures should be referred to the
appropriate surgeon.
7. The oral mucosa is altered under a removable denture t h a t
has been worn.
8. Bruxism may produce destructive changes in the supporting
tissues of removable dentures.
9. Because favorable response to loading from a prosthesis has
been observed in both dense and porotic bone, bone density seen
radiographically does not always predict a response to loading.
10. Bone resorption may be caused by many factors.
11. When possible, optimal periodontal health should be estab-
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A C A D E M Y OF P R O S T H O D O N T I C S
lished before completion of definitive restorative and prosthetic
treatment. A thorough periodontal examination should contribute
to a diagnosis t h a t can help establish a logical treatment plan. Re-
ferral to a periodontist may be helpful.
C. Factors in diagnosis
1. For patients with orofacial defects, a psychosocial evaluation
may be a valuable aid for diagnosis and development of a and
treatment plan.
2. Factors t h a t improve diagnostic capabilities include in-depth
knowledge of anatomy, embryology, histology, physiology, micro-
biology, patholody, psychology, biochemistry, pharmacology, and
the physiology of oral function.
3. Maxillofacial defects may be congenital, acquired, or devel-
opmental.
4. Normal growth patterns should be understood so t h a t devi-
ations can be recognized and evaluated.
5. Healing processes of oral and perioral hard and soft tissues
should be understood.
6. Inflammation may cause changes in the appearance and
function of the oral mucosa.
7. Drug effects and interactions must be understood by both
patient and dentist.
8. Aging causes change in body tissues, organs, and function
that may affect patient response to a prosthesis.
9. Dimensional reduction of bone supporting dentures may lead
to loss of the vertical dimension of occlusion.
10. Determining the vertical dimension of occlusion is usually
a matter of judgment. Commonly used methods and guidelines in-
clude the following:
(a) A measurement of 3 mm less than physiologic rest posi-
tion
(b) An evaluation of the closest speaking space
(c) Proprioception or patient preference
(d) Swallowing on soft wax cones
(e) Relative parallelism of ridges
(f) General appearance of the midfacial profile
11. The vertical dimension of rest is a postural position that is
subject to change.
12. A record of the maxillomandibular relationship with the
mandible in terminal hinge position is considered a necessary
component of a comprehensive diagnosis.
13. Altering the vertical dimension of occlusion requires critical
judgment. When a vertical dimension is to be altered, a trial pe-
riod at the new position may be used to ascertain whether the new
position is physiologically acceptable.
14. The occlusion of any patient that was established by
prosthodontic procedures should be periodically reevaluated.
15. In maximum intercuspation, all posterior teeth should con-
tact simultaneously.
16. Deflective occlusal contacts may cause altered mandibular
positions to shift.
17. Systemic conditions should be identified for adequate
treatment planning. They can affect etiology, pathogenesis, and
treatment of periodontal disease. They have the potential to alter
periodontal health.
D. Treatment plan considerations
1. Structures that provide valuable support, stability, and
retention for a maxillofacial prosthesis should be preserved.
2. T r e a t m e n t procedures for patients to be treated with dental
implants should include articulated diagnostic casts with a trial
arrangement of artificial teeth on trial denture bases. A presurgi-
cal prosthodontic diagnosis is essential for implant site location
and angle.
3. Selection of a fixed or removable partial denture is largely
dependent on the number, location, condition, and supporting
structures of the abutment teeth and the size and contour of the
edentulous spaces.
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A C A D E M Y OF P R O S T H O D O N T I C S
PROGNOSIS
1. A prognosis is an opinion or judgment about the prospects for
success of therapy and restoration. Since prognosis is a forecast of
probable results, it is given in advance of treatment.
2. Good oral hygiene and plaque control positively influence
natural dentition and the longevity of restoration.
3. The oral cavity should be healthy before placement of defin-
itive restorations.
4. Proper selection of materials and the skillful execution of
treatment enhance treatment success.
5. Tissue tolerance and patient adaptability affect the progno-
sis for the tissue-borne prosthesis.
6. Clinician and patient compatibility and clinician manner
during treatment influence treatment success.
7. General health and nutrition may influence the patient's
ability to use any prosthesis.
8. Psychological factors may pose insurmountable obstacles to
successful denture wearing.
9. As physical defects become larger, successful prosthesis
wearing is more likely to be compromised.
PRERESTORATIVE TREATMENT
Systemic and local
1. Altered oral mucosa may be the manifestation of such
systemic disorders as diabetes, avitaminosis, or hormonal imbal-
ances. This may indicate the need for supportive therapy before
initiating prosthodontic treatment.
2. Dietary counseling may benefit prosthodontic patients with
unfavorable tissue response, particularly senescent individuals.
3. Proper preparation of remaining oral structures enhances the
success of a removable prosthesis.
4. Conditioning the oral mucosa and orofacial musculature for
patients requiring removable prostheses is important.
5. The patient's emotional status may influence the success of
prosthodontic treatment.
6. Denture-stimulated gagging may have a psychologic compo-
nent.
Patient education
1. Informed patients are usually more receptive and cooperative
than uninformed patients.
2. Treatment with dentures is individual and cannot be stan-
dardized.
3. Speaking about prosthodontic treatment is more desirable
than focusing solely on making the denture.
4. Patients should be educated about the value and the short-
comings of complete dentures.
5. A prospective patient should be informed that neuromuscu-
lar adaptation contributes to success in wearing a removable pros-
thesis.
6. Both oral and printed information can help patients under-
stand and accept treatment goals.
7. Education, instruction, and discussion about dental care
should continue during the entire treatment period and during re-
call visits.
8. Successful dental treatment is enhanced if the patient prac-
tices thorough oral hygiene. The dentist is responsible for teach-
ing such procedures, and the patient is responsible for performing
them.
9. Patients should be informed t h a t residual ridge resorption
occurs in varying, unpredictable degrees. It will affect the adapta-
tion and function of their dentures.
10. Patients should be discouraged from using "do-it-yourself"
denture relining kits because of their hazards.
11. Plaque control instructions and frequent periodic prophy-
laxis should be part of care for patients who have had radiation
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T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
therapy to the head or neck. A through oral examination is essen-
tial. Fluorides should be self-administered daily.
12. Patient education and disease control should include the
following:
(a) Teaching about diagnosis, etiology, and consequences of
disease
(b) Training in personal plaque control and care of prosthetic
restorations
13. Before treatment completion, patients should be given the
following information:
(a) The prognosis, both periodontally and prosthetically, is
influenced by diet, systemic factors, and their ability to
maintain a plaque-free environment.
(b) Even with proper professional and personal care, period-
ontal disease may recur.
(c) A doubtful prognosis for teeth retained after periodontal
therapy could compromise the longevity of the restora-
tion. When possible, such teeth should be extracted before
or during periodontal therapy.
TREATMENT OF O R A L S T R U C T U R E S
1. Each treatment procedure should be directed toward pre-
serving oral tissues and normal functions to the extent possible.
2. Before missing structures are replaced with a prosthesis, pa-
thosis of hard and soft oral tissues should be corrected when pos-
sible. Treatment procedures (not in order of priority) may include
the following:
(a) Periodontal therapy
(b) Oral surgery procedures, including placement of implants
(c) Occlusal corrections
(d) Operative dentistry
(e) Endodontics
(f) Orthodontics
(g) Crowns and/or fixed partial dentures to restore satisfac-
tory functional relationships
3. Traumatic occlusion should be treated appropriately. Treat-
ment may include interocclusal splints, occlusal restorations, se-
lective occlusal adjustments, surgery, orthodontics, muscle exer-
cise, or other corrective methods.
4. Before an impression is made for a removable prosthesis, a
program of tissue conditioning should be considered when soft
tissue is inflamed, irritated, or distorted.
5. If the examination shows the presence of periodontal disease,
a periodontal consultation should be held.
6. Before the final preparation of abutment teeth, periodontal
pathosis should be treated, and periodontal health should be sta-
bilized.
7. When a patient is referred to a periodontist, the prosthodon-
tic treatment plan under consideration should accompany the
written referral request. The periodontist should be advised of the
criteria remaining teeth must meet if they are to be retained as part
of a prosthodontic treatment plan.
8. Plans for periodontal treatment may include the following:
(a) Instruction in daily oral hygiene
(b) Removal of supragingival and subgingival calculus
(c) Smoothing of root surface irregularities where appropri-
ate
(d) Posttreatment evaluation of periodontal health
(e) Reinforcement of daily oral hygiene and plaque control
care when needed
(f) Recontouring supporting bone
(g) Reorganization or augmentation of unattached gingiva
(h) Extraction before periodontal therapy of teeth lack
proper supporting structures, crown form, or position
t h a t would compromise the prognosis of a prosthesis
9. Treatment options when the periodontal condition is more
severely involved may include the following:
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T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
(a) Pocket reduction through the use of soft and hard tissue
surgical procedures
(b) Grafting procedures.to enhance lost periodontal tissues
and to provide an adequate zone of attached gingiva,
particularly around teeth being prepared for prosthodono
tic treatment
(c) Occlusal therapy to reduce occlusal trauma
(d) Minor tooth movement
10. Postoperative patient care is the joint responsibility of the
periodontist and the prosthodontist, if the patient is treated by
both specialists.
REEVALUATION AND REFINEMENT OF
TREATMENT PLAN
1. After prerestorative treatment is completed, the treatment
plan should be reevaluated and modified as indicated by patient
response to the following:
(a) Education
(b) Efforts to eradicate or control disease
(c) Exploratory and trial procedures
2. After completion of active periodontal therapy, supportive
care, including regular reevaluations of the periodontal status, re-
inforcement of personal oral hygiene, and removal of any etiologic
factors is critical to the long-range maintenance of patient health.
PROSTHODONTIC TREATMENT
I. B a s i c to m o s t a r e a s o f p r o s t h o d o n t i c s
A. Design, fabrication, and classification
1. Selection and final arrangement of artificial teeth are the re-
sponsibility of the dentist in consultation with the patient.
2. Artificial teeth should be arranged for minimal inhibition of
the tongue, so t h a t palatal vault is not substantially altered.
3. The external form of the prosthesis should be compatible
with the function of the oral musculature and overlying tissues.
4. Before extensive preprosthetic surgery is considered, patient
experience with an existing prosthesis should be evaluated care-
fully.
5. The relationship of tuberosities to retromolar pads is best vi-
sualized with diagnostic cases. Such casts should be articulated in
centric relation at an acceptable vertical dimension of occlusion.
6. There should be accommodation for the coronoid process
during normal functioning range of mandibular movement in the
retrozygomatic area of the maxillary denture base.
7. To control lateral stress to an abutment tooth as much as
possible, the retainer should be designed to direct forces along the
long axis of the tooth.
8. The prosthodontist should know and understand the phys-
ical and chemical properties of all materials used in the practice
of prosthodontics.
9. Dimensional changes occur in resin materials during pro-
cessing procedures.
10. Dimensional changes in dentures can occur from differences
in coefficients of thermal expansion in gypsum products, resins,
and metal flasks. Dentures should be processed with techniques
t h a t minimize these changes.
11. Four areas of concern in the fabrication of any new prosthe-
sis are (1) comfort, (2) function, (3) esthetics, and (4) phonetics.
12. The design and fabrication of all restorations, provisional
and definitive, should promote periodontal health.
13. Areas of concern in the design and fabrication of all resto-
rations include margin placement, margin adaptation, contour of
the restoration, and occlusal relationships.
14. The prosthodontic design should consider
(a) Crown-root ratio
(b) Length of the edentulous space
(c) Root configuration and size
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A C A D E M Y OF P R O S T H O D O N T I C S
(d) Contour of the anterior edentulous ridge
(e) Occlusal-gingival dimension
(f) Size and configuration of the clinical crown
(g) Occlusal scheme
(h) Materials to be used
B. Tooth preparation and soft tissue management
1. The mucosa in edentulous regions may assume an altered
surface form and texture resulting from being covered by denture
bases.
2. Surgery may be desirable to alter ridge contours, reduce pen-
dulous tissues, and reposition tissue attachments.
3. Surgery may be indicated to improve maxillomandibular
ridge relationships.
4. When a maxillary tuberosity approximates the retromolar
pad or is pendulous, it may be reduced. This procedure is indicated
to provide the desired interarch distance, a more stable denture
base, or to permit proper orientation of the occlusal plane.
5. Before final impressions are made, irritated, inflamed, or
distorted mucosa should be brought to maximum health.
6. Tissue conditioning is more effective when
(a) The occlusion is corrected
(b) The proper vertical dimension of occlusion is restored
(c) Denture borders are properly extended
(d) The conditioner is properly placed and changed as
required
7. Tissue-conditioning materials placed on the tissue surface of
a surgical prosthesis can help compensate for tissue alterations re-
suiting from surgery.
8. Before denture placement, areas on the tissue surface t h a t
cause excessive pressure on the tissues should be identified and
relieved.
9. Inflammatory papillary hyperplasia may require surgical re-
moval before definitive treatment to prepare a maxillary arch to
accept dentures.
10. Patients should be informed that the success of prosth-
odontic restorations depends on meticulous plaque control. Pa-
tients should be instructed in the proper maintenance of oral
health.
11. Oral surgery procedures are indicated to reduce tuberosi-
ties, tori, or other hard or soft tissue interferences. In such situa-
tions, the diagnostic cast or its duplicate may be recontoured to the
desired shape. A clear plastic template may be constructed also, or
instead, to aid the surgeon achieve the desired residual ridge con-
tour.
12. When a residual ridge presents unfavorable gingival con-
tours for pontic placement, augmentation and/or revision should
be considered.
C. Impressions
1. Custom impression trays, correctly designed and contoured,
will facilitate making impressions for fixed or removable partial
dentures, complete dentures, and implant prostheses.
2. Impression trays for final impressions should remain dimen-
sionally stable throughout the impression and cast-making proce-
dure.
3. Preliminary impressions made with modeling plastic impres-
sion compound may be altered by trimming and/or adding mate-
rial so that they may be used as final impression trays.
4. Displacement or deformation of soft and pendulous tissues
should not occur during final impression making.
5. Final impression borders should represent the extension and
contours of the processed denture.
6. Maximum extension of denture bases, within physiologic
limits, is helpful to distribute forces to the supporting structures,
augment retention and stability, and minimize accumulation of
food particles under the bases.
7. Soft tissue displacement during impression-making may be
partially controlled through the placement of relief in the tray, by
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A C A D E M Y OF P R O S T H O D O N T I C S
escape holes in the tray, and/or control of impression materials'
viscosity.
8. When plaster of paris, zinc oxide-eugenol paste, or similar
materials are used for final impressions, sufficient space be-
tween the impression tray and the mucosa should be present.
This applies in making both complete and removable partial
dentures.
9. When gagging is a problem while impressions are being made,
placing the patient in an upright or forward position, and/or judi-
ciously applying a topical or infiltration anesthetic agent to the
posterior palatal area and the posterior part of the tongue can aid
in managing the problem.
10. The manufacturer's instructions for each impression mate-
rial should be carefully followed for optimum results.
11. Making impressions for diagnostic casts may provide useful
knowledge about the patient, including unusual sensitivities of the
mucosa structures, the tendency toward gagging, tolerance to oral
procedures, and favorable and unfavorable tongue movements.
D. Casts
1. Diagnostic casts are helpful for diagnosis, treatment plan-
ning, patient education, and as a permanent record of the status
of the dentition.
2. All materials used in prosthodontics should be carefully se-
lected. The materials should meet ADA specifications where pos-
sible and be used in accord with manufacturers' instructions.
3. To produce accurate dies and casts, impression materials,
gypsum products, and other die materials should be mutually
compatible.
4. The cast should be completed immediately after the impres-
sion-making procedure or within the time recommended by the
manufacturer of each material.
5. When cast materials are mixed, the manufacturers' recom-
mendations for the powder-to-water ratio should be followed.
6. Impressions should not be inverted on the same mix of stone
when casts are formed; t h a t is, either a two-pour or a boxing tech-
nique should be used.
7. The cast produced from an impression should accurately
record all of the details captured in the impression, including the
border contours.
8. Ordinary plaster of paris is not a suitable material for
constructing master casts.
9. When hydration of a gypsum-materials cast is mandatory,
avoid disintegration of the cast's surface. The cast should be
soaked in slurry water instead of tap water.
10. Accurately mounted diagnostic casts with and without the
patient's removable prostheses may be necessary as an adjunct to
proper diagnosis.
11. Unaltered diagnostic casts may be an important part of the
patient's treatment record.
12. Suitable means should be used to prevent the record base
and other materials from adhering to or distorting casts.
13. Diagnostic waxing, tooth arrangement, or other preliminary
procedures on articulated casts are helpful in diagnosis, treatment
planning, and making final restorations.
14. In mounting any cast in an articulator, procedures and ma-
terials t h a t minimize dimensional changes between the mounted
cast and the member of the articulator should be used.
15. Vacuum mixing and correct water-powder ratios are essen-
tial in mixing final cast materials.
16. Casts should be properly trimmed according to their in-
tended use.
17. The accuracy of casts made from impressions may be
checked with an occlusal index made in the mouth.
E. M a x i l l o m a n d i b u l a r r e c o r d s a n d r e g i s t r a t i o n s
1. Temporomandibular joints are capable of three-dimensional
movements.
2. A necessary component of comprehensive diagnosis is a
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T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
record of the maxillomandibular relationship when the mandible
is in centric relation.
3. When posterior teeth are missing and mastication has oc-
curred only on the anterior teeth, an eccentric functional relation
of the mandible to the maxilla may have occurred. It should be
recognized before jaw relation records are made.
4. Unilateral loss of posterior teeth may alter the relationship
of the condyle to the glenoid fossa. Where possible, the proper
conditioning or positioning of the condyles should be accom-
plished through prosthodontic services.
5. As used in dentistry, the term vertical dimension refers to the
length of the patient's facial profile established by raising and
lowering the mandible in relation to the maxillae (opening or clos-
ing the jaws).
6. The term rest vertical dimension refers to the length of the
patient's facial profile when the mandible is in its rest position in
relation to the maxillae.
7. Mandibular rest position is a postural position and is subject
to the same physiologic and pathologic factors as posture else-
where in the body. Thus, it is subject to change and may not be
constant throughout life.
8. The interocclusal distance, when added to the vertical
dimension of occlusion, equals the rest vertical dimension.
9. Although the interocclusal distance is relatively stable, it can
vary with time; but variations are usually small.
10. Patients can best assume mandibular rest position when
sitting erect in a chair without a headrest or back support or when
standing erect.
11. In the absence of occlusal interference or pathosis, the
mandible normally tends to return to its physiologic rest position
after most functional movement.
12. Opposing teeth or occlusion rims should not be in contact
when the mandible is in its physiologic rest position.
13. Reference points placed on the face may aid in registering
vertical jaw relationships.
14. Before teeth are arranged in the denture base, properly as-
sessing the correct dimension of occlusion can be difficult.
15. Altering the vertical dimension of occlusion requires critical
judgment. Use of interim diagnostic restorations at the altered
vertical dimension may be indicated.
16. Tissue changes t h a t occur when dentures are worn may
cause a loss of the vertical dimension of occlusion.
17. When parts of the natural dentition are missing, some ver-
tical dimension of occlusion may be lost.
18. Recording maxillomandibular relations is best accomplished
when the patient is relaxed. Therefore, patients should be trained
to relax the muscles controlling the mandible before centric rela-
tion records are made.
19. Centric relation serves as a reference for analysis of an ex-
isting occlusion and for determining the type of occlusion to
establish during treatment.
20. Centric relation is individual to each patient.
21. On an articulator, centric relation at a particular vertical
dimension of occlusion may not be the same at another vertical
dimension of occlusion, unless the transverse horizontal axis
determination has been made.
22. A new centric relation record should be made if it becomes
necessary to alter the originally established vertical dimension of
occlusion unless a transverse horizontal axis determination has
been made.
23. Head position influences the recording of centric relation.
24. Centric relation records should be made with minimum
closing pressure.
25. Centric relation records should be repeatable.
26. Eccentric jaw relation records are made to adjust the guid-
ing elements of an articulator.
27. Recording the centric relation for a removable prosthesis
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requires rigid and accurately fitted bases that resist warpage dur-
ing clinical use.
28. Properly adapted record bases should be stable on the casts.
They should incorporate an accurate index on the occlusion n m
into which they may be related for mounting casts on an articu-
lator.
29. Record bases should not be adapted to severe undercuts on
the casts. This might warp the bases or damage the casts when they
are removed.
30. Shellac-type record bases are susceptible to deformation.
31. Thick record bases may interfere with recording jaw rela-
tions accurately.
32. Occlusion rims should be made of a material with the
following characteristics:
(a) Easily softens and molds to the desired form
(b) Easily attaches to the record base
(c) Becomes sufficiently rigid when cooled to serve as a tem-
porary occlusal surface
(d) Permits resoftening in selected areas
33. The labial, buccal, and lingual contours of occlusion rims
may influence the results when jaw relation records are made. This
consideration is especially important when phonetic determina-
tions are used.
34. Recording jaw relations may be more accurate when the de-
sign of occlusion rims conforms to the positions and dimensions
originally occupied by the natural teeth and their investing tissues.
35. If an average-value facebow is used, interocclusal centric
relation records should be kept to a minimum thickness.
36. To set condylar guidance, factors such as the nature and ex-
tent of prosthodontic therapy and health of the stomatognathic
system, instead of statistical averages determine the need for re-
cording condylar movement.
37. A remount procedure on a suitable articulator with new
maxillomandibular records is an effective method of identifying
occlusal discrepancies before placement of a prosthesis.
F. Occlusion
1. Because occlusal relationships are not static, the neuromus-
cular reflexes may change in response to changes in the occlusal
position.
2. All prosthodontically treated patients should receive sched-
uled reevaluation of occlusion.
3. Opposing tooth contacts should be planned to allow free
movement throughout the functional range of the mandible.
4. Artificial posterior teeth should be arranged to provide
equalized contact in centric relation with no interference in
eccentric excursion.
5. The factors of articulation directly under the control of the
dentist during complete denture fabrication are (1) anterior guid-
ance, (2) plane of occlusion, (3) cusp height, and (4) compensating
curve.
6. Occlusion and articulation of artificial teeth should be phys-
iologically compatible with the remaining natural teeth and other
parts of the masticatory system.
7. In centric occlusion, all posterior teeth should contact simul-
taneously.
8. Orthodontic procedures may play an important role in cor-
recting some occlusal disharmonies.
9. Occlusion should be analyzed, and necessary occlusal alter-
ations should be completed before final impressions and a pros-
thesis are made.
10. Before an attempt is made to create artificial occlusal sur-
faces in the partially edentulous patient, occlusal discrepancies in
the natural teeth should be eliminated.
11. A thorough examination of the occlusion of the remaining
natural teeth should include properly mounted diagnostic casts.
12. Tooth contact of the teeth during speech may indicate in-
sufficient interocclusal distance.
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A C A D E M Y OF P R O S T H O D O N T I C S
13. Physiologic stimulation of teeth and ridge structures is ad-
visable. Excessive forces or dysfunction can be harmful and
destructive.
14. Eccentric occlusions can be developed to meet the patient's
physical and neuromuscular requirements.
15. An acceptable vertical dimension of occlusion contributes to
optimum function, acceptable interocclusal distance, comfort,
satisfactory speech, and good appearance.
16. Extreme caution should be exercised when performing pro-
cedures that will change the vertical dimension of occlusion. If the
existing vertical dimension of occlusion is to be altered, a trial pe-
riod at the new position is recommended to ascertain that a phys-
iologically acceptable position has been established.
17. Incisal guidance is important in establishing anterior tooth
position and the occlusal patterns of posterior restorations.
18. The absence of harmony between the intercuspal position
and centric relation may cause prosthodontic failure.
19. The occlusion of all new dentures should be refined after
processing.
20. Abnormal swallowing closures do not necessarily terminate
at centric relation.
21. Provision of food escapeways in artificial posterior teeth
enhances chewing effectiveness.
22. Occlusal morphology and cuspal patterns should be devel-
oped to satisfy the patient's needs instead of to fulfill a stereotyped
concept of cuspal form.
23. The protrusive movement has two elements that should be
considered in articulation:
(a) Condylar inclination, which is established by the patient
(b) Incisal guidance, which is determined by the dentist's
judgment and the patient's esthetic demands and func-
tional needs
G. Try-in and verification procedures
1. Mandibular artificial posterior teeth should not be positioned
farther distally than the anterior border of the retromolar pad, nor
should they be positioned on the distal incline of the residual ridge.
2. When only the anterior teeth in a partially edentulous arch
remain, the artificial posterior teeth should be arranged on a record
base and tried in the patient's mouth to verify the jaw relations,
occlusion, and appearance.
H. Esthetic considerations
1. The color of naturalanterior teeth may become more uniform
as their incisal edges become worn. They may not present the same
incisal edge translucency found in most artificial teeth.
2. Natural anterior teeth often have a lower color value and ac-
quire a smoother surface as the patient ages.
3. Facial templates or facial measurements may be helpful in
arranging artificial teeth.
4. Photographs, diagnostic casts, and radiographs made before
complete extractions are valuable guides to satisfactory esthetics.
5. Irregular or asymmetric arrangement of artificial anterior teeth
may enhance the natural appearance of prosthetic restorations.
6. Compromises between esthetics and function should be
assessed and discussed with the patient before treatment is
started.
7. Preextraction records may be helpful during future treat-
ment. They become part of the patient's record before any
remaining natural teeth are removed.
8. A preextraction profile record of the face is best made while
the teeth are in maximum contact.
9. Dentists are responsible for esthetics. Their work authoriza-
tions to technicians should give specific instructions regarding es-
thetic factors.
10. Appropriate terminology should be used in communicating
to the dental technician about tooth color.
11. Dental treatment rooms and the dental laboratory need
similar light conditions for optimum shade matching.
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ACADEMY OF PROSTHODONTICS
12. Esthetic features of restorations should be observed in ar-
tificial and natural light.
13. Shade selection should be made under conditions t h a t sim-
ulate natural daylight.
14. Resin denture base materials should optimally reproduce
the color and characteristics of oral tissues being replaced.
15. Incisal length of maxillary anterior teeth should be deter-
mined esthetically and phonetically by arranging the teeth on the
record base.
16. The natural appearance of replacement teeth may be
enhanced if various tooth colors and molds are used in arranging
the anterior teeth artistically.
17. Reflective surface and texture are critical to attaining a
shade match.
18. Modification of standard artificial teeth may improve the
appearance of a removable prosthesis, especially for the mature
patient.
19. The dentist needs a working knowledge of the science of
color to match the colors of natural teeth.
20. A patient's esthetic requirements should be met with due
consideration for the periodontal health of the tissues and proper
function. Rigid esthetic requirements t h a t conflict with functional
requirements may preclude treatment.
L Initial placement of restorations (insertion)
1. Adequate time should be allowed for appointments involving
initial placement of restorations so t h a t patients fully comprehend
the importance of their responsibilities in the success of the res-
torations.
2. Each denture base tissue surface should be evaluated and
corrected, if necessary, before occlusal evaluation and place-
ment.
3. At the preliminary placement of the prosthesis, all areas
should be checked with pressure indicator material and all inter-
fering regions should be assessed for selective relief.
4. Written instructions to the patient regarding home care and
maintenance of the prostheses and oral tissues are positive rein-
forcements of verbal instructions. Such instructions can become a
future informational reference.
5. After the initial placement of a removable prosthesis, the pa-
tient should be recalled for necessary adjustments at an appropri-
ate interval.
6. Explanation of common sensations and effects of wearing a
prosthesis should precede initial placement of the prosthesis.
J. Care after placement
1. Prosthodontic treatment is a continuous service t h a t does not
end with the placement of the oral or facial prosthesis.
2. The patient should be impressed with the need for routine
examinations to evaluate the occlusion and assess the oral envi-
ronment's response to the prosthetic restoration.
3. Proper diet should be emphasized to all prosthodontic
patients.
4. The patient's name, date, articulator number, condylar set-
tings, and other pertinent data should be indelibly recorded on
articulated diagnostic casts, treatment casts, and dies. The dentist
should retain them. These records are a valuable aid for planning
further treatment and for medicolegal reasons.
5. Care after placement should include maintenance and care of
prosthetic restorations.
K. I n t e r i m and i m m e d i a t e restorations
1. After surgery and appropriate healing, the original prosthe-
sis may require revision or replacement.
2. Properly constructed interim restorations may alleviate some
temporomandibular joint symptoms.
3. An acceptable method of compensating for tissue changes
after surgery is to place tissue-conditioning materials on the tis-
sue surface of a surgical prosthesis.
4. To help the patient adapt to wearing a prosthesis, a transi-
J A N U A R Y 1995
THE JOURNAL OF PROSTHETIC DENTISTRY
tional removable partial denture may be considered as a temporary
treatment modality before immediate complete dentures.
5. Immediate restorations are generally considered provisional,
to be followed later by definitive treatment.
II. F i x e d p a r t i a l d e n t u r e s
A. Diagnostic procedures
1. For most fixed partial dentures, the patient's diagnostic casts
should be mounted in a semiadjustable or fully adjustable artic-
ulator capable of accepting eccentric excursive and centric relation
records.
2. The maxillary cast should be mounted in the articulator with
the aid of a face-bow.
3. Pantographic tracings may provide additional diagnostic in-
formation about the patient's jaw movements.
4. Casts mounted in an articulator should be evaluated
(a) To determine anteroposterior and lateral excursive in-
terferences
(b) To select the appropriate path of placement
(c) To decide whether to alter the vertical dimension of oc-
clusion to provide the desired plane of occlusion
(d) To determine the types of dental restorations needed
(e) To aid in pontic selection
(f) To accomplish trial equilibration procedures
5. A diagnostic wax-up of proposed restorations is indicated in
some situations:
(a) To provide useful information relative to the intended
esthetic result
(b) To indicate the required amount of tooth reduction
(c) To aid in making provisional restorations
(d) To provide a visual aid during treatment-planning dis-
cussions with the patient
(e) To plan occlusion
6. A second set of mounted casts may be used for trial tooth
preparation.
7. A customized incisal guide table may be developed by use of
the mounted diagnostic casts.
B. Tooth preparation
1. Preparation of a tooth should be planned and completed to
achieve adequate retention and to develop resistance form.
2. Adding boxes, grooves, or pinholes to a preparation may in-
crease a cast metal restoration's resistance to dislodgement.
3. Sufficient tooth structure must be removed to preserve the
integrity of the restoration, provide the desired esthetic result, and
allow the restoration to be fabricated without being overcon-
toured. The amount of tooth reduction needed will vary depend-
ing on the restorative material being used.
(a) Occlusal reduction for a cast metal restoration should be
a minimum 1.0 to 1.5 mm for the lingual cusps of the
maxillary teeth and the buccal cusps of the mandibular
teeth.
(b) Preparation of occlusal surfaces should replicate as nearly
as possible the anatomy of the cusps and grooves to avoid
over or under reduction of the tooth.
(c) Peripheral reduction, especially near the margins, should
be adequate to increase rigidity of the casting.
(d) Boxes, grooves, ledges, and occlusal shoulders may be
used to increase the rigidity of a casting.
4. Supragingival placement of cast restoration margins may be
desirable if requirements for retention, resistance form, and
esthetics are satisfied.
(a) If subgingival margin placement is necessary, an adequate
zone of attached gingiva should be present.
(b) Whenever possible, the margins of a restoration should be
accessible to the dentist for finishing and to the patient
for cleaning.
(c) The finish line should be placed on enamel if possible. In
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THE JOURNAL OF PROSTHETIC DENTISTRY
some situations, it may be necessary to locate the finish
line on cementum, dentin, amalgam, or gold. Placing the
finish line on composite resin should be avoided.
(d) There should be no occlusal margins in an area of occlusal
function.
(e) During tooth preparation, the formation of a well-defined
finish line such as the knife edge, chamfer, chamfer with
a bevel, shoulder, and shoulder with a bevel is desirable
(f) The type of restorative material used and the location of
the tooth being restored may dictate the choice of finish
line.
5. Tooth preparation should be accomplished with minimal
pulpal trauma. Teeth should be prepared in relation to healthy
tissue.
6. During tooth reduction with rotary instruments, use of an air
and water coolant is recommended.
7. Endodontically treated teeth may require the use of a core
buildup or a dowel and core to obtain the desired retention and
resistance form.
8. Periodontal health should be established before or in concert
with the restorative treatment.
9. Preservation of supporting structures should be a primary
consideration in designing and making fixed partial dentures.
10. The gingival terminus should not violate the epithelial at-
tachment.
C. Impressions
1. An impression material should be selected because its phys-
ical, chemical, and working properties are best suited for the clin-
ical problem being treated.
2. Impression materials should meet ADA Council on Dental
Materials, Instruments, and Equipment specifications.
3. When elastomeric impression materials are used, a full-arch
custom tray may facilitate making impressions.
4. Gingival displacement may be accomplished by using me-
chanical, chemical, or electrosurgical methods.
(a) Gingiva should be healthy and free of inflammation
before final tooth preparation.
(b) Care must be exercised to avoid violating the integrity of
the epithelial attachment, no matter what method of gin-
gival retraction is employed.
(c) Epinephrine-impregnated cords should not be used on
patients with certain types of cardiovascular disease, hy-
perthyroidism, or a history of epinephrine hypersensitiv-
ity.
(d) Electrosurgical gingival preparation should not be used
on patients with cardiac pacemakers.
5. Careful management of the interface between tooth and pe-
riodontium is integral to preserving periodontal health. Ideally, an
impression should not extend subgingivally, however, certain
clinical situations may necessitate subgingival margin placement.
Invasive techniques to displace gingival tissue should be minimally
traumatic.
D. Interocclusal records
1. The time lapse between securing an interocclusal record and
its use in mounting casts in an articulator should be consistent with
minimizing inaccuracies inherent in the recording material being
used.
2. After the working casts have been recovered from the
impressions, a separate appointment for making interocclusal
records will enable records verification while the patient is present.
3. Numerous materials and techniques will enable accurate re-
production of interocclusal relationships. Personal preference and
clinical circumstances will dictate which methods are used.
4. Interocclusal records t h a t are trimmed so that only cusp tip
indentations remain, facilitate accurate cast positioning in the
record before they are mounted in an articulator.
5. When limited numbers of teeth are being restored, the
80
ACADEMY OF PROSTHODONTICS
interocclusal registration may be made with the remaining unpre-
pared teeth in contact. The recording medium should avoid
increasing the vertical dimension of occlusion and thus possibly
incorporating an inaccuracy into the mounting.
6. Interocclusal registrations made with the teeth out of contact
should be recorded bilaterally. The dentist should guide the
patient to the desired centric relation or lateral excursive position.
7. An occlusal programmer or jig provides a vertical stop at the
desired degree of vertical opening. It also assists positioning the
condyles appropriately.
8. Lateral excursive recordings may be made by guiding the pa-
tient in a lateral movement until the opposing arches are in a
cusp-tip to cusp-tip relationship. The recording medium then
captures t h a t relationship.
9. To verify the accuracy of the centric relation mounting of the
mandibular cast in the articulator, at least two registrations should
be used.
10. When a significant edentulous segment exists, an interoc-
clusal record to relate the casts for a fixed partial denture should
be made with a stabilized record base fabricated on the master
cast.
11. Making interocclusal registrations, positioning the casts in
the registration, and mounting them in the articulator are the
dentist's responsibility.
E. P r o v i s i o n a l restorations
1. Provisional restorations should incorporate the same quali-
ties as the final restoration, including marginal integrity, esthet-
ics, form, and function, while maintaining the health of the abut-
ment teeth and supporting structures.
2. Many acceptable materials are available for making provi-
sional restorations. Tooth position in the arch, type of tooth prep-
aration, expected length of service, and whether it is a single unit
or a fixed partial denture will influence the choice of material.
F. Ocelusal considerations
1. A cusp-marginal ridge occlusal relationship is found in most
adult natural occlusions. This type of occlusal morphology may be
used in making either single or multiple cast restorations.
2. A cusp-fossa occlusal scheme is rarely found in natural teeth.
It is often advocated when multiple adjacent and opposing teeth
are being restored with cast restorations to direct the forces of oc-
clusion in a more axial direction.
3. A group function occlusion may distribute the occlusal load
on the working side in lateral excursions.
4. The functionally generated path technique is an effective way
to develop a group-function occlusion in cast restorations.
5. A mutually protected occlusion may be indicated under these
conditions:
(a) There are periodontally healthy anterior teeth.
(b) There is an Angle's class I jaw relationship.
(c) The posterior teeth are not in a reverse occlusion. (The
maxillary and mandibular buccal cusps interfere with
each other in a lateral excursive movement.)
6. In a mutually protected occlusion, only the anterior teeth are
in contact in any excursive position of the mandible. Maximum
intercuspation is coincident with centric relation. Occlusal forces
are directed along the long axis of the posterior teeth. Anterior
teeth protect the posterior teeth in eccentric movements. Posterior
teeth protect anterior teeth in the intercuspal position.
7. Lateral excursive contacts on the balancing side are consid-
ered undesirable in either a group-function or mutually protected
occlusion.
8. In making anterior restorations, care must be exercised so
t h a t the vertical and horizontal overlap and configuration of the
lingual surfaces of the maxillary restorations are in harmony with
the patient's functional movements.
9. When the vertical dimension of occlusion is to be increased
or decreased, it is advisable to have a trial period. During several
VOLUME 73 NUMBER 1
A C A D E M Y OF P R O S T H O D O N T I C S
weeks to several months, the patient is allowed to function at the
desired vertical dimension of occlusion before the definitive resto-
rations are made.
G. Casting try-in and verification
1. After the provisional restorations are removed, the prepared
teeth should be examined carefully to assure they are free from
temporary cement or any other debris before placement of the de-
finitive restoration is attempted.
2. A binocular microscope may be used to verify t h a t internal
surfaces of cast restorations are free of small bubbles, investment,
or deposits of veneering material. Then, placement on the pre-
pared tooth can be attempted.
3. A disclosing medium may be used on the interal surface of a
casting to locate discrepancies t h a t prevent the restoration form
seating completely on the prepared tooth.
4. Proximal contact areas of fixed restorations should be firm
yet allow the passing of dental floss to maintain good oral hygiene.
5. Pontics should be designed to contact the residual ridge in a
passive manner.
6. The apical form of the pontic should be designed and
adjusted to enable the patient to maintain good oral hygiene.
7. In equilibrating the occlusal discrepancies of definitive res-
torations, relatively smooth rotary instruments and a thin mark-
ing medium should be used.
8. During equilibration of the definitive restorations, articulat-
ing strips of different colors can be used to help differentiate be-
tween centric and lateral excursive interferences.
9. When numerous teeth are being restored, a remount proce-
dure may facilitate occlusal equilibration of the definitive restora-
tions.
10. When access allows, margins of cast restorations should be
refined on the tooth with the restoration in place.
11. To achieve the maximum esthetic result with ceramic res-
torations, the dentist should perform final surface characteriza-
tion, contouring, and shade modification with the patient present.
12. Fixed partial dentures replacing anterior teeth should pro-
vide lip support and satisfy the patient's esthetic, phonetic, and
functional requirements.
13. The trial fitting procedure should include procedures that
verify complete seating of castings, marginal integrity, proper em-
brasure spaces, and contour for periodontal health.
14. It may be helpful to have individual units indexed from an
intraoral try-in before soldering.
H. Cementation
1. In areas where adjustments have been made, metal should be
repolished and porcelain polished or reglazed before cementation.
2. To assess tissue and patient response, trial placement of the
restoration with a temporary cement may be indicated.
3. The cement selected should meet the specifications of the
American Dental Association Council on Dental Materials, In-
struments, and Equipment.
4. Different types of cements are available for final placement
of a restoration. The dentist should select the cement with the
physical, chemical, and working properties best suited to each
clinical situation.
5. The tooth should be cleansed, isolated, and dried. Where in-
dicated, a cavity varnish should be applied before final cementa-
tion.
6. The manufacturer's instructions for manipulating the ce-
ment should be strictly followed.
7. When multiple individual restorations are to be placed, each
restoration should be cemented individually to assure complete
seating.
8. After the cement has set, all of the extraneous material should
be removed so t h a t none remains to act as a gingival irritant.
9. The occlusion should be reexamined after cementation and
should be equilibrated, if necessary.
JANUARY 1995
T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
10. Patients should be thoroughly instructed regarding oral hy-
giene procedures, aids, and devices t h a t facilitate interproximal
and pontic tissue surface cleansing.
11. The patient should be given a follow-up appointment for
after-placement care.
I. Periodic recall e x a m i n a t i o n
1. Periodic recall after placement should be an essential part of
fixed prosthodontic therapy.
2. Early detection of potential problems through recall exami-
nation may prevent failure of the restorations.
III. Removable partial dentures
A. Refining diagnostic procedures and preparatory
treatment
1. Occlusion of the teeth should be compatible with normal
function of the stomatognathic system. It may be necessary to treat
the patient with occlusal splints, occlusal adjustment, or orth-
odontics to restore proper harmony between the musculature, the
temporomandibular joints, and the occlusion of the teeth.
2. When treating a patient with a removable partial denture, the
patient's periodontal health is an important consideration.
3. Criteria for selecting removable partial denture abutment
teeth include the following:
(a) Crown-root ratio of the teeth
(b) Number of roots
(c) Form and curvature of roots
(d) Alveolar support (amount of bone)
(e) Tooth inclination (position in the arch)
(f) Mobility (periodontal health)
(g) Stress evaluation
(h) Previous response to stress
(i) Restorability of the tooth
(j) Occlusal relationships
(k) Crown contour
(1) Plaque control
(m) Impending functional demands
4. Diagnostic casts mounted in an articulator assist in locating
elements of the removable partial denture that relate to esthetics,
design, and function. Spatial requirements for rest placement and
preparation can be evaluated.
5. Diagnostic casts are necessary to evaluate the degree of
mouth preparation and tooth modification required for removable
partial denture framework design.
6. Planned mouth preparation and tooth modification may be
carried out on the diagnostic cast before actual patient prepara-
tion, and can serve as a guide for subsequent intraoral procedures.
7. A dental surveyor must be used to locate undercuts and to
guide surfaces in relation to the planned path of placement on the
diagnostic cast.
8. Guiding surfaces are parallel surfaces that will contact a rigid
part of the removable partial denture. Adequate guiding surfaces
should be planned to establish the path of placement and
dislodgement. Properly prepared guiding surfaces contribute to
the retention and stability of the removable partial denture.
9. Because diagnostic casts are made by using stock trays and
a viscous impression material, they may not be a reliable guide to
soft tissue reflections, anatomy, and contour (for example, vesti-
bular depth, frenum movement).
B. Design, fabrication, and classification
1. Treatment planning, mouth preparation, and designing re-
movable partial dentures are the dentist's professional responsi-
bilities. They must be completed before master casts are presented
to the dental technician or dental laboratory where the prosthesis
will be made.
2. Classification of a partially edentulous arch should permit
immediate visualization of the type of arch being considered. This
classification should also permit immediate differentiation be-
81
T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
tween the tooth-borne and tooth-tissue-supported removable
partial denture.
3. Philosophies of removable partial denture support are based
on principles of broad or selective distribution of occlusal forces.
4. The basic purposes of removable partial dentures' compo-
nent parts are (1) to provide support by means of rests on abut-
ment teeth and by denture bases on edentulous ridge areas; (2) to
provide primary retention by direct retainers; and (3) to provide
selective force transmission through placement of the rigid com-
ponents of the removable partial denture.
5. A removable partial denture should restore arch integrity,
thereby preventing further change of both maxillary and mandib-
ular arches.
6. Maintaining and improving the health of the remaining teeth
and supporting structures is an important consideration in re-
movable partial denture design. Prosthesis impingement on gingi-
val tissues should be avoided. Impingement of any part of the
prosthesis on gingival tissues should be avoided.
7. When a removable partial denture is supported by both nat-
ural teeth and the residual ridge(s), the design should use both
supporting units to their greatest potential.
8. In some instances, support and stabilization are as significant
as retention in the design of a removable partial denture.
9. Retention of a removable partial denture is important for
management of patient care, particularly for the first months af-
ter placement of the denture.
10. Removable partial dentures should be constructed to trans-
mit occlusal forces to the abutment tooth nearly parallel to its long
axis.
11. The design, contour, and finish of a removable partial den-
ture should minimize food retention or impaction.
12. A survey of both the diagnostic and master casts is essential
for making removable partial dentures.
13. One method of stress distribution to abutment teeth is the
use of multiple abutments.
14. An isolated premolar adjacent to a distal extension base may
not be an adequate primary abutment for a removable partial
denture. The prognosis can be improved by splinting with a fixed
partial denture. : the existing natural teeth.
15. Forces that produce torque on abutment teeth and the:al-
veolar residual ridge should be controlled and minimized h ~he
design of direct retainers for distal extension removable phrtial
dentures.
16. A removable partial denture with distal extension bases may
use stress directors to minimize stress distribution on a b u t m e n t
teeth.
17. Major connectors should be designed to have sufficient
rigidity to distribute forces throughout the dental arch.
18. Most removable partial dentures move during function. The
extent and direction of movement are influenced by the support-
ing structures, prosthesis design, and the accuracy of fit of frame-
work and bases.
19. A removable partial denture base t h a t derives part of its
support from the residual ridge should not displace the underly-
ing mucosa except during masticatory function.
20. In tooth-tissue supported removable partial dentures, den-
ture bases should provide optimum support during occlusal load-
ing.
21. The form of the denture base for a mandibular distal exten-
sion removable partial denture should be similar to that required
for a complete denture. Modification may be dictated by the path
of placement.
22. In surveying a cast for a removable partial denture, the re-
lationship of the vertical spindle of the surveyor to the cast indi-
cates the most desirable path for placement and removal of the
completed restoration.
23. Abutment teeth should be prepared by modifying unfavor-
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A C A D E M Y OF P R O S T H O D O N T I C S
able contours and preparing guiding surfaces and rest seats before
the impression for the master cast is made.
24. Fixed restorations used as abutments for removable partial
dentures should incorporate guiding surfaces, rest seats, stabiliz-
ing, and retentive areas.
25. Fixed restorations t h a t are to be integrated with removable
prostheses should be surveyed in the wax pattern stage and ver-
ified after casting, after veneering, and before cementing.
26. Indirect retainers establish a positional reference point for
the removable partial denture. They also provide better stress
distribution by transferring forces to structures other than the
a b u t m e n t teeth.
27. A direct retainer (clasp) should be passive when the remov-
able partial denture is in place and at rest.
28. Intracoronal or extracoronal retainers may be used in com-
bination with stress-directing devices in extension base removable
partial dentures.
29. Whenever possible, retainer elements should be kept at the
same height relative to survey lines on opposing tooth surfaces so
t h a t unfavorable forces on abutments will be minimized.
30. Each direct retainer (clasp) requires reciprocation to reduce
movement of the abutment tooth during placement and to avoid
dislodgment of the removable partial denture.
31. For a direct retainer to be effective, components of the
framework must contact the abutment tooth at three points or ar-
eas encircling more than 180 degrees of the tooth.
32. When appearance is a consideration, a direct retainer
(clasp) design that will minimize the display of metal should be
chosen.
33. The undercut gauge indicates the amount of infrabulge at
the selected site. It also indicates the distance which a retentive
clasp arm must flex or deform to pass over the greatest contour of
the tooth.
34. Direct retainers (clasps) should pot engage undercuts that
require deflection beyond the yield strength of the metal being
used.
35. Multiple occlusal rests and other supportive elements may
provide a more advantageous transfer and distribution of forces to
36. Occlusal and incisal rests are important supporting ele-
ments of removable partial dentures. They help resist horizontal
and vertical forces applied to the prosthesis. Other components that
contact teeth above the survey line may also provide stability.
37. The major connector should be located so that its contact is
compatible with structures t h a t move during function and gingi-
val impingement is avoided.
38. Direct measurements of the distance between the active
floor of the mouth and the lingual gingival tissues are essential to
selection and placement of mandibular major connectors.
39. Major connectors join the denture base(s) to other parts of
the removable partial denture and help distribute functional
forces.
40. The angle formed by the occlusal rest and the vertical mi-
nor connector should be slightly less than 90 degrees.
41. The use of permanent soft denture base material for defin-
itive removable partial denture fabrication is not recommended.
42. When lingual inclinations of remaining teeth contraindicate
the use of a conventional lingual major connector, mandibular la-
bial bar major connectors may be used.
43. A hinged continuous labial bar may be indicated for patients
with missing key abutments, unfavorable tooth contours, unfa-
vorable soft tissue contours, and teeth with questionable progno-
sis.
44. The use of porcelain teeth should be limited to instances in
which the opposing occlusal surfaces will not be subject to accel-
erated functional wear.
45. When there is aberrant spacing in the edentulous area,
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A C A D E M Y OF P R O S T H O D O N T I C S
acrylic resin teeth should be considered for use in removable par-
tial dentures.
46. Clasp elasticity varies in its length, thickness, width, curva-
ture, taper, form in cross section, metallurgical composition, and
handling.
47. The dentist is responsible for producing the work authori-
zation or design. The dental technician is responsible for follow-
ing it and creating a removable partial denture framework that
accurately fits the undamaged master cast. If these criteria are met
and the framework does not fit the mouth, the fault lies with er-
rors occurring before the technical work.
48. The removable partial denture's metal framework must not
prevent the contact of natural teeth in occlusion, unless an increase
in vertical dimension is planned.
49. Overdenture abutments can provide support for removable
partial dentures.
50. An overdenture abutment supporting a removable partial
overdenture may contact the metal framework or the acrylic resin
of the denture base.
51. The use of acrylic resin contact with overdenture abutments
in removable partial overdentures has several advantages:
(a) The abutment tooth may be recontoured or shortened
and the denture base readapted with autopolymerizing or
visible-light-cured resin.
(b) A coping can be placed at a later date and the denture
base readapted.
(c) There are fewer problems in making an altered east im-
pression or relining the denture base.
(d) The denture base can be adapted to the abutment tooth
under some degree of occlusal loading of the artificial
teeth.
C. Tooth p r e p a r a t i o n and soft tissue management
1. The occlusal rest should be spoon-shaped and deeper in its
central portion. The preparation's surface angles should be
rounded and the preparation should be highly polished.
2. Spoon-shaped occlusal rest seats prepared in sound enamel
are satisfactory to support a removable partial denture.
3. A rest seat on an anterior tooth should be placed on a recon-
toured lingual or incisal surface. The resultant force should be di-
rected parallel to the long axis of the tooth. When recontouring is
not feasible, a restoration t h a t incorporates a rest seat may be re-
quired.
4. Rest seats must (1) be strong enough to endure functional
stress; (2) preferably be prepared in enamel or a metallic restora-
tion; (3) provide a vertical contact for the metal framework; (4) be
rounded and conform to the existing coronal anatomy; and (5)
have a preparation sufficiently deep to prevent rest fractures. The
opposing dentition may require modification to provide space for
adequate rest thickness.
5. If possible, rests should not be located on habitual occlusal
contacts.
6. Cingulum rest seats may be prepared in teeth having a nat-
urally accentuated cingulum.
7. Cingulum rest seats should have an outline that blends into
tooth contours.
8. Incisal rest seats should be shaped as a rounded groove ex-
tending onto the labial surface of an anterior tooth and gingivally
on the lingual surface. Incisal rest seats are used principally on
mandibular anterior teeth.
9. An occlusal strap rest is a continuous occlusal rest extending
through prepared central grooves of a group of natural teeth to
provide stabilization of the dentition.
10. Teeth to be used as abutments for a removable partial den-
ture should have favorable contours or be recontoured or restored
as needed. Some tooth alteration is usually necessary for patients
who initially receive removable partial dentures.
11. Heights of contour may be altered and guiding surfaces cre-
JANUARY 1995
T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
ated to aid retention and stability of the removable partial
denture.
12. Guiding surfaces should be (1) aligned to the path of inser-
tion; (2) curved buccolingually to follow tooth form; (3) straight
occlusogingivally; and (4) dispersed in the arch as much as possi-
ble.
13. Guiding planes should be completed on the unrestored
abutment teeth before crowns or other teeth are constructed.
Thus, they serve as a guide for crown contours.
14. To permit better framework placement, the following may
be recontoured: (1) line angles of crowded anterior teeth that will
receive a lingual plate or continuous clasp; (2) proximal line angles
of tipped or rotated teeth; and (3) buccal and lingual surfaces of
tipped teeth.
15. The fixed splinting of teeth to be used as abutments for re-
movable partial dentures may be indicated when the bone support
of the abutment(s) is unfavorable or when rigid retainers are
planned.
16. Fixed splinting of teeth may aid in counteracting forces t h a t
result in torque of abutment teeth.
17. Contiguous teeth and those separated by an edentulous
space may be splinted together to provide more support for the
removable partial denture.
18. Natural tooth surfaces t h a t have been modified must be
highly polished and should receive fluoride treatment.
19. Before impressions are made for a new removable partial
denture, soft tissues that have been distorted and displaced by a
previous removable partial denture should be returned to normal
health and contour.
20. Plans for correcting discrepancies in the plane of occlusion
should be noted during the diagnosis and incorporated into the
treatment plan.
21. Tooth contours on removable partial denture abutment
teeth may be altered in certain situations through the use of com-
posite resins or metal castings bonded to acid-etched enamel
D. Final impressions
1. When properly used, reversible and irreversible hydrocol-
loids and elastomeric impression materials may be acceptable for
removable partial denture impressions.
2. One concept of making impressions uses a secondary impres-
sion (altered cast removable partial denture impression) to record
the supporting tissues of the denture base. Mandibular distal ex-
tension removable partial dentures usually require a secondary
impression technique or relining procedure to improve the stabil-
ity and support of the prostheses.
3. One potential complication of the altered cast impression
procedure is incorrect or incomplete seating of the framework in
the mouth or on the cast.
4. Final impressions should be carefully inspected to verify t h a t
(1) all critical soft and hard tissue areas are accurately recorded;
(2) voids are not present in rest seats; and (3) the impression ma-
terial had not separated from the tray.
5. The impression tray must be carefully positioned and held
without movement until the impression material completely
sets.
6. Hydrocolloid impressions should be poured immediately af-
ter removal from the mouth.
7. Most final impressions should be cleaned of saliva and other
debris, disinfected, and poured in improved stone immediately
after removal from the mouth. A few impression materials require
a delay in pouring.
8. When the posterior teeth are missing, the final impression of
the partially edentulous mandibular arch should include the ret-
romolar pad.
9. A posterior palatal seal on a removable partial denture with
full palatal coverage may prevent the ingress of food and aid in re-
tention during forceful expulsion of air through the mouth.
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E. Casts
1. The master cast must be an exact replica of the oral
structures. It should be (1) dense, (2) clear of debris, (3) without
critical voids, and (4) possess an adequate base.
2. Master casts for removable partial dentures should be disin-
fected.
3. Master casts should be produced with an improved dental
stone compatible with the material used for making the impres-
sion.
4. Duplicate casts are helpful to communicate removable par-
tial denture design to the technician. Diagnostic casts are not rec-
ommended for this purpose if restorative procedures or recon-
touring have significantly altered the contours of teeth subsequent
to making diagnostic impressions.
5. The design of the removable partial denture framework
should be drawn either on the master cast or on a duplicate of the
master cast to transmit this information to the technician.
6. If needed for proper occlusal and framework relationships, an
opposing cast mounted in an articulator should be provided to the
technician as a guide in waxing the framework.
7. At its thinnest area, a master cast should be at least 8 mm
thick.
8. All casts submitted to the laboratory for framework fabrica-
tion should be trimmed so that the base is flat, the walls are ver-
tical, and the land areas are definite. Mandibular casts should have
flat smooth lingual land areas.
9. Accurate casts that have been neatly trimmed, carefully de-
signed, surveyed, blocked out, and tripoded may instill a desire for
the highest quality work from the technician.
F. Framework try-in
1. Initial seating of the framework should be gentle and slow to
allow minor repositioning of the abutments.
2. All parts of the framework must be completely seated.
3. Vertical elements of the framework for tooth- and tissue-
supported removable partial dentures must be physiologically ad-
justed to minimize undesirable stress on abutment teeth during
prosthesis movement.
4. Occlusal surfaces of the framework must be in harmony with
the occlusion of the natural teeth.
5. Most removable partial denture frameworks require some
adjustment to achieve their optimal fit. Fitting can best be accom-
plished by using a disclosing medium.
6. Unless the framework is completely seated, retentive clasp
arms of removable partial dentures may not be passive.
7. Extracoronal or intracoronal attachment removable partial
dentures capable of vertical movement under stress should be ad-
justed to optimal occlusion before the vertical movement of the
attachment occurs.
G. Maxillomandibular records
1. Before preparing an a b u t m e n t and related teeth, it may be
helpful to refer to an accurate occlusal record used to mount di-
agnostic casts in an articulator at the proper vertical dimension.
2. The recording of maxillomandibular relation records for dis-
tal extension removable partial dentures requires accurately
adapted denture bases attached to the framework. This system
should relate to the remaining teeth correctly.
3. For patients whose prognosis is good, and in whom the exist-
ing occlusion is physiologic, interocclusal registrations should be
made with the natural teeth in contact at maximum intercuspa-
tion.
4. Before a definitive occlusal pattern or arrangement is devel-
oped for patients who show evidence of traumatogenic occlusion,
interocclusal registrations should be made in centric relation.
5. Maxillomandibular records for distal extension removable
partial dentures should be made with minimal pressure.
6. A semiadjustable articulator is adequate to develop tooth ar-
rangement for most removable partial dentures.
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A C A D E M Y OF P R O S T H O D O N T I C S
7. In tooth- and tissue-supported removable partial dentures,
the recording of maxillomandibular relationships is best per-
formed by using record bases attached to frameworks fabricated
after an altered cast impression procedure.
8. The vertical dimension of occlusion established for the
removable partial denture must be coincident with the remaining
natural dentition.
H. Occlusion
1. To articulate properly, the occlusion of a removable partial
denture should be developed with the remaining natural teeth at
the correct vertical dimension of occlusion.
2. Contact only in maximum intercuspation is usually required
in removable partial dentures opposing natural dentitions.
3. Before removable partial denture service is provided, the
occlusal surfaces of opposing natural teeth may require adjust-
ment.
4. Nonworking-side contacts usually are undesirable for remov-
able partial dentures opposing natural teeth or another removable
partial denture.
5. Generally, no part of the removable prosthesis should inter-
fere with complete closing contact or eccentric movements of the
remaining natural dentition.
6. Dentitions t h a t include removable partial dentures provide
less masticating efficiency than natural dentitions with similar
contact areas.
7. Processed removable partial dentures may be returned to the
articulator before removal from the master cast to adjust for pro-
cessing changes. This procedure reestablishes and verifies the in-
tended vertical dimension of occlusion.
8. Distal extension removable partial dentures may be re-
mounted in the articulator to refine centric and eccentric occlusal
contacts. This adjustment should follow base modification by us-
ing indicator paste.
9. Short-span tooth-supported removable partial dentures may
have the static and dynamic occlusal relationships perfected in the
patient's mouth.
10. Occlusal relationships of tooth-supported removable partial
dentures may be perfected in the patient's mouth if opposed by
natural teeth or another partial denture.
I. Try-in of the waxed removable partial denture
1. A try-in with the artificial teeth arranged in wax attached to
the framework is usually necessary.
2. Articulator mounting accuracy should be verified at the
try-in appointment.
3. The appearance of the removable partial denture should he
satisfactory to both patient and dentist.
4. Anterior artificial teeth should be tried in the mouth to ver-
ify their size, shade, position, and acceptability to the patient.
5. When esthetics is a primary concern, it may be helpful to have
a relative or friend of the patient present at the try-in appoint-
ment.
6. Before the denture base material is processed, waxing should
be accomplished for proper esthetic form and for physiologic
function.
7. Artificial teeth should be positioned for optimal centric rela-
tion and eccentric contacts.
8. After the accuracy of the vertical dimension of occlusion has
been determined, centric relation should be verified.
J. Esthetic considerations
1. In designing direct retainers for removable partial dentures,
effect on appearance should be considered.
2. Artificial teeth adjacent to a b u t m e n t teeth may be contoured
to accommodate retainers.
3. In the partially edentulous patient with a well-formed ante-
rior residual alveolar ridge, anterior teeth t h a t are adapted to the
ridge with no labial denture base may provide optimum appear-
ance.
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ACADEMY OF PROSTHODONTICS
K. Initial denture placement
1. Denture base border extension and thickness should be ver-
ified during placement.
2. The denture bases and major connector should be checked
with disclosing medium to identify areas of undesirable pressure.
3. The occlusion may require adjustment to provide planned
contacts in maximum intercuspation and lateral excursions.
4. Verbal or written home care instructions with demonstra-
tions are recommended.
5. When undercut areas prevent the seating of the denture bases
of removable partial dentures, judicious adjustment is required.
The tissue surfaces of posterior bases are relieved so that border
extent can be maintained. Anterior bases are shortened and con-
toured to blend with the remaining tissues to avoid an unnatural
appearance.
6. Removable partial denture frameworks must be fully seated
on the supporting structures before occlusal adjustment.
L. Care after placement of removable partial dentures
1. A major factor in the success of a removable partial denture
is proper maintenance of the prosthesis and the supporting struc-
tures.
2. Most patients who have removable partial dentures should be
reexamined at least semiannually and more frequently, if indi-
cated.
3. Written instructions aid in educating patients effectively.
4. To help patients cleanse removable partial dentures and
supporting teeth, properly designed brushes and appropriate
cleansing instructions should be provided.
5. Instructions for cleansing and stimulation around abutment
teeth and the remaining natural teeth are essential.
6. Application of fluoride to the natural teeth by means of the
prosthesis or an individual applicator may be indicated.
7. Removable partial dentures should usually be removed from
the mouth when the patient goes to bed.
8. Distal extension removable partial dentures should be exam-
ined periodically for evaluation of ridge resorption, stability,
occlusion, and framework displacement. Variations from optimum
should be corrected.
M. Interim restorations
1. Interim removable partial dentures may facilitate residual
ridge remodeling. They may also help maintain the vertical
dimension of occlusion after removal of posterior teeth.
2. Interim removable partial dentures can be used for the fol-
lowing diagnostic purposes:
(a) In determining proper vertical dimension of occlusion
(b) In determining esthetic and phonetic requirements
(c) To assess patient ability to cooperate
(d) To assess patient ability to cope with wearing a prosthesis
IV. Maxillofacial prosthetics
A. Scope of maxillofacial prosthetics
1. In a society t h a t values appearance, those who lack eyes, ears,
noses, facial and mandibular tissues, or who exhibit severe scar
tissue and malformed parts of the face, neck, and oral cavity may
become socially alienated. Whereas developmental defects afford
more time for adjustments to be made, a sudden traumatic and
surgical defect may precipitate a crisis in the patient's quality of
life. Maxillofacial rehabilitation of the patient requires a broad
knowledge of prosthodontics and the capacity for compassionate
patient management.
B. Refining diagnostic procedures
1. The maxillofacial prosthodontist is an integral member of an
interdisciplinary team that treats individuals with oral, cranial,
and facial defects.
2. Evaluation of the needs of a patient requiring maxillofacial
care generally includes (1) dental history, (2) medical history, (3)
surgical history, (4) psychosocial assessment, (5) speech evalua-
JANUARY 1995
THE JOURNAL OF PROSTHETIC DENTISTRY
tion, and (6) clinical examination. Diagnostic aids include (1) ar-
ticulated maxillary and mandibular casts, (2) oral radiographs,
and (3) radiographs of related facial structures if required.
3. When possible, all prospective patients for head and neck
surgery and potential candidates for any maxillofacial prosthesis
should be seen by the maxillofacial prosthodontist for diagnosis
and pretreatment evaluation before surgery, radiation therapy, or
chemotherapy.
4. The prosthetic prognosis for patients after irradiation is less
favorable because of changes in supporting structures. Consider-
ation must be given to (1) trismus, (2) fibrosis, (3) xerostomia, (4)
hypogeusia, (5) radiation, (6) caries, (7) soft tissue fragility, and (8)
osteoradionecrosis.
5. Corrective surgery may be indicated to improve function,
comfort, and natural appearance for patients requiring maxillofa-
cial prostheses.
6. All dental structures t h a t may provide valuable retention and
support of a maxillofacial prosthesis should be preserved.
7. Facial prostheses are indicated when no further reconstruc-
tive plastic surgery is to be performed or when an immediate or
provisional prosthesis is needed after resective surgery.
8. The ideal material for facial prostheses should be (1) biolog-
ically compatible, (2) flexible, (3) translucent, (4) able to retain
extrinsic and intrinsic color, (5) easy to clean, (6) lightweight, (7)
durable, (8) color stable, (9) inexpensive, (10) easy to fabricate, and
(11) finishable to a fine edge.
9. The palatal lift prosthesis is indicated for palatal incompe-
tency. It elevates the middle segment of the soft palate to approx-
imate the posterior and lateral walls of the pharynx.
10. A palatal lift prosthesis may increase the activity and range
of motion of the incompetent soft palate.
11. A speech-aid prosthesis is indicated to correct a palatopha-
ryngeal deficiency or incompetency when surgical repair is de-
ferred or contraindicated.
12. An obturator feeding aid may assist in the normal feeding
of an infant with a cleft palate. It can be discontinued when the
infant can eat normally without it.
13. Preparing a patient for an obturator prosthesis may require
supportive dental treatment, including restorations for the re-
maining dentition of both dental arches to achieve proper support
and retention of the prosthesis.
14. After a hemimandibulectomy including the condyle, the
patient should be instructed in exercises, or the patient may have
a mandibular resection prosthesis with a guide made to minimize
mandibular deviation toward the resected side on closure.
15. The prognosis for edentulous mandibulectomy patients be-
comes less favorable as the size of the resection increases.
16. A prosthesis placed at the time of surgery can aid the
patient's immediate postoperative convalescence.
17. A surgical obturator is generally delivered during the surgi-
cal procedure for resection of the maxillae.
18. Certain oroantral and oronasal palatal defects require sim-
ple coverage by the prosthesis base; others need obturation by ex-
tension of the prosthesis base to enhance retention, stability, and
support of the completed restoration.
19. To enlarge the contracted socket before an acceptable arti-
ficial eye can be constructed, a custom conformer prosthesis, which
sequentially increases in size, may be required.
20. Until definitive surgery is performed, maxillofacial pros-
theses may be transitional restorations.
C. Design features and considerations
1. A maxillofacial prosthesis should be designed and fabricated
so t h a t the residual anatomic structures will perform the functions
of speech, respiration, mastication, and deglutition with minimal
impediment.
2. Maximum tissue coverage supported by residual bone is de-
sirable for maxillofacial prostheses.
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T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
3. A surgical obturator prosthesis should be (1) lightweight, (2)
strong, (3) easy to repair and alter, (4) easy for the patient to place
and remove.
4. Sometimes the patient's existing complete maxillary denture
may be converted into an acceptable surgical obturator prosthe-
sis.
5. The use of hollow extensions is indicated when the weight of
the prosthesis will compromise retention and place undue stress on
the surrounding tissues.
6. For added retention of the prosthesis, resilient, flexible ma-
terials t h a t extend into desirable undercut areas of nasal or pala-
tal cavities may be used.
7. To maintain prostheses during growth, development, and
postsurgical healing, use of resilient or adaptive lining materials
may be indicated.
8. The pharyngeal part of a speech-aid prosthesis should extend
to the level of maximal muscle activity in the nasopharnyx. Nor-
mally, this will be slightly above the anterior tubercle of the first
cervical vertebra or on the palatal plane in the adult patient.
9. The palatal extension section can be made of a cast metal bar
that traverses the soft palate anteroposteriorly and ends in a re-
tention loop midway in the nasopharyngeal cavity.
10. Speech-aid prostheses should be fabricated in maxillary,
palatal, and pharyngeal sections. Each section may require refit-
ting and use by patient before succeeding sections are made.
1t. A facial prosthesis should be formed so t h a t peripheral bor-
ders are thin, translucent, and blend with facial anatomy to con-
ceal the edges of the prosthesis.
12. Use of the following auxiliary aids for retention of maxillo-
facial prostheses should be considered on an individual basis.
(a) Resilient material into the undercuts
(b) Spectacle, frames
(c) Intermaxillary springs
(d) Sectional swivel hinges
(e) Magnets
(f) Implants
(g) Adhesives
13. To obtain retention from the remaining abutment tooth, a
mandibular resection prosthesis should include multiple retainers.
When minimal retentive undercut areas are available, swinglock or
faciolingual continuous retainers may be employed.
14. When possible, contours of facial prostheses should harmo-
nize with the natural contralateral side and remaining areas of the
face from full-face, superior, and inferior views.
15. Intrinsic tinting of the facial prosthesis within the tolerance
of the material will provide the most stable color.
16. Unfavorable anatomic relationships may limit the degree to
which satisfactory appearance can be realized in maxillofacial res-
torations.
17. Direct retainers for maxillofacial prostheses should have
strong stabilizing characteristics and enhance retention on abut-
ment teeth.
18. Orthodontic bands with buccal tubes or appropriately con-
toured crown preparations on permanent or deciduous teeth can
be used to retain a maxillofacial prosthesis.
19. The auditory meatus of an auricular prosthesis should align
with the natural auditory meatus to assure normal hearing.
20. An orbital prosthesis can be made for placement after
orbital resection.
21. A surgical obturator prosthesis improves speech, mastica-
tion, and deglutition; it maintains skin graft packings in position,
and it may improve patient morale.
22. Using acrylic resin artificial teeth for maxillofacial prosthe-
ses is usually advisable.
23. This holds true even though the long spans and extended
denture bases that incorporate maxillofacial prostheses pose spe-
cial design problems.
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A C A D E M Y OF P R O S T H O D O N T I C S
24. The basic principles of support, stability, and retention re-
main the same for long spans and extended denture bases as for
conventional removable partial dentures.
D. Tooth a l t e r a t i o n s in e n a m e l
1. In maxillofacial prosthetics, the following aspects are basi-
cally the same as for conventional removable partial dentures:
(a) Recontouring enamel judiciously to improve esthetics
(b) Preparing guide planes
(c) Removing interferences
(d) Preparing rest seats
(e) Correcting occlusal disharmonies
(f) Using methods to augment retention
2. In developmental deformities, tooth positions may be more
aberrant than normal. They may require an overdenture design
after coronal reduction and complete coping coverage have been
completed.
3. Although the remaining teeth and alveolar bone are of greater
relative value in the maxillofacial patient, motivation for plaque
control and good oral hygiene is often less t h a n desirable.
4. In situations involving chronic tissue abuse with lack of
proper oral hygiene and routine dental care, the dentist should
exercise caution in the use of tissue conditioner relines, particu-
larly where they may contact highly sensitive respiratory mucosa.
E. Final i m p r e s s i o n s
1. Impression procedures for extraoral and intraoral defects are
influenced by the character of the remaining tissues.
2. Impressions for diagnostic casts of maxillofacial prosthetic
patients may require recording structures not normally included
in impressions for conventional prosthodontic patients.
3. Because of their drying and irritating effects on oral mucosa,
metallic oxide and plaster impression materials are contraindi-
cated for many irradiated patients.
4, A complete or sectional facial impression may be indicated
for making an orbital prosthesis.
5. A sectional facial impression is acceptable in the fabrication
of an auricular or nasal prosthesis.
6. The maxillofacial patient should be seated in a nearly upright
position while the facial impression is being made.
7. Complete and sectional facial impressions may be made with
irreversible hydrocolloid material supported with a plaster of paris
backing.
8. The form and position of the pharyngeal section of any
speech aid is determined by visual inspection, speech evaluation,
and the patient's response.
9. In making any speech-aid prosthesis, the nasopharynx im-
pression should be made during speech, postural movements, and
swallowing.
10. Usually, an impression material that can be physiologically
molded is the best for making impressions of the nasopharyngeal
regions.
11. Because the lateral wall and the scar band of the maxillary-
resected patient are dynamic, functional impression materials,
such as dental impression wax, may be needed for an improved
border seal.
F. M a s t e r c a s t s
1. Master casts for maxillofacial patients require the same con-
siderations and qualities as for removable partial denture casts.
G. F r a m e w o r k try-in
1. Framework try-in and maxillomandibular recording proce-
dures are similar to those for removable partial dentures.
2. Making jaw relation records on large mobile record bases re-
quires additional care to avoid displacement of the record base
during registration.
3. When jaw relation registrations are attempted, discontinuity
defects of the mandible require special skills, methods, materials,
and patience.
4. With the loss of mandibular continuity, some movements of
V O L U M E 73 NUMBER 1
ACADEMY OF PROSTHODONTICS
the remaining mandible can be recorded. Currently, no articulat-
ing instrument is capable of accepting all these functional records
and their aberrations.
5. Mandibular resections may hinder repeating centric relation
position. Thus, an acceptable functional jaw record should have a
consistent pattern of duplicable relationships made without ten-
sion or force.
H. W a x try-in
1. Wax try-in procedures are similar to those for complete and
removable partial dentures.
2. Processed acrylic resin bases have value for early testing of
fit, comfort, retention, and stability of prostheses associated with
maxillofacial defects.
3. Before final processing, a clay or wax sculpture with a prop-
erly aligned artificial eye should be used for trial fittings of an or-
bital prosthesis.
I. Occlusion
1. Changes in the tissues supporting a maxillofacial prosthesis
may be more rapid than in those supporting a more conventional
prosthesis. Therefore, the occlusion and base adaptation must be
reevaluated frequently. Corrections can be made by selective
grinding of the occlusion or refitting the base of the prosthesis.
2. All occlusal patterns in maxillofacial reconstructions must be
physiologically compatible with the patient's residual anatomic
structures and functional capabilities.
3. Occlusal stress should be minimized for the irradiated patient
requiring complete dentures. Acrylic resin teeth with a reduced
occlusal contact area may be indicated.
4. Altering the cusp angle of posterior teeth may influence the
stability of the prosthesis placed on an edentulous resected max-
illa or mandible.
5. It may be necessary to accept an occlusion that is not bilat-
erally balanced in eccentric occluding positions for an edentulous
resected maxilla or mandible.
6. When needed, occlusal ramps or platforms may be placed on
the opposing maxillary prosthesis to direct the resected mandible
into a more desirable maxillomandibular relationship.
J. Initial placement
1. Initial placement procedures are similar to those for remov-
able partial dentures. There should be special emphasis on patient
education.
2. Placement of a surgical obturator prosthesis for maxillary
resections may eliminate the need for or facilitate early removal of
a nasogastric tube.
3. Placement of a surgical obturator prosthesis may help to
shorten the patient's hospital recovery period.
4. Extensions of the prosthesis should be evaluated and ad-
justed to acceptable positions.
K. Initial care after placement
1. After placement, the focus is on the care and cleaning of the
prosthesis and on maintaining the health of the remaining oral
structures.
2. Speech therapy is often necessary after placement of any
speech-aid prosthesis for a cleft palate patient.
3. Speech-aid prostheses for patients with soft palate defects
may require adjustment in the size and contour of the pharyngeal
section, because wearing the prosthesis may stimulate palatopha-
ryngeal changes.
4. It may be necessary to place tissue-conditioning material in
a newly placed prosthesis, before refitting with more permanent
materials.
5. Rehabilitation of the maxillofacial patient after surgery may
require speech assessment, psychosocial evaluations, physical
therapy, and vocational guidance.
6. Patients with oral neoplasms often have a history of mouth ne-
glect and poor oral hygiene. Preventive dentistry and education in good
oral hygiene are necessary components of effective aftercare.
JANUARY 1995
THE JOURNAL OF PROSTHETIC DENTISTRY
7. Facial prostheses require periodic replacement because of
tissue changes and the unstable properties of available materials.
8. Adhesives used to retain facial prostheses should be
(a) Nonirritating and nontoxic to the skin and mucous mem-
brane
(b) Sufficiently flexible to move with surrounding tissues
(c) Compatible with the material of the facial prosthesis and
the patient's skin
(d) Strong enough to retain the prosthesis
(e) Easily cleaned from tissue and prosthesis
(f) Stable
(g) Incapable of supporting bacterial growth
9. Frequent reevaluation is necessary for maxillofacial patients
because of possible rapid tissue and occlusal changes often asso-
ciated with the use of unstable restorative materials.
10. Surgical orbturator prostheses provided for a maxillary re-
section must be relined periodically during the healing period to
assure patient comfort and function.
V. Complete dentures
A. Refining diagnostic procedures
1. Many signs of systemic disorders, such as diabetes or avita-
minosis, manifest themselves in mucosal structures; these may in-
dicate the need for other therapy before prosthodontic treatment.
2. Nutritional guidance should be a part of treatment for many
complete denture patients.
3. Psychologic maladjustment may result from associating
denture wearing with advancing age.
4. Patients with psychotic tendencies may use their maladjust-
ments to dentures to avoid traumatic interpersonal situations with
friends, relatives, and others.
5. Prosthodontic treatment for patients who have had radiation
therapy in or about the oral cavity should carefully take into ac-
count time of radiation therapy, radiation methods, and radiation
dosage.
6. Most irradiated patients can wear removable prostheses if
the effects of radiation therapy are not severe and the patient fol-
lows instructions for the use of the prosthesis.
7. The risk of osteoradionecrosis is greater in the mandible than
in the maxillae.
8. Important physical criteria for establishing a prognosis are
(1) evaluation of the patient's arch form, (2) cross-sectional shape
of the alveolar ridges, (3) retromylohyoid extensions, and (4)
tongue position
9. Relief or alteration of the denture base to accommodate un-
dercuts associated with root eminences of overdenture abutments
may cause reduced retention, stability, and border seal.
10. Patients for whom overdentures are planned should be in-
formed that overdentures may be less stable and retentive than
fixed or removable partial dentures.
11. Endodontic treatment of an overdenture abutment is usu-
ally required so t h a t the tooth can be reduced sufficiently to allow
placement of the artificial tooth esthetically.
12. Overdentures should only be considered if the patient can
achieve and maintain satisfactory oral hygiene.
B. Design features and considerations
1. The space available for complete dentures is controlled in
part by the oral and circumoral structures surrounding the space
and their movements in function.
2. Maximum coverage and intimate contact of the denture
foundation area are essential for the support of a complete denture
prosthesis.
3. The dentist should establish a posterior palatal seal for the
maxillary complete denture either in the impression procedure or
by proper alteration of the master cast.
4. The posterior palatal seal should extend bilaterally through
the pterygomaxillary notch areas.
87
THE J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
5. Palatal relief should not be routinely placed in the maxillary
complete dentures.
6. Artificial anterior porcelain teeth should not be used with
posterior artificial acrylic resin teeth, but anterior artificial acrylic
resin teeth may be used with posterior artificial porcelain teeth.
7. Intimate tissue contact and border seal permit atmospheric
pressure to serve as an important physical factor in complete den-
ture retention.
8. Neuromuscular control contributes to complete denture re-
tention and stability. It becomes increasingly effective in the ex-
perienced denture patient.
9. Optimum denture retention at denture placement can help
the patient learn the neuromuscular control needed to use com-
plete dentures effectively.
10. Anatomic regions that resist resorptive changes most effec-
tively should be covered to promote long-term support and min-
imize changes in the relation of the denture to the maxillae or
mandible. Horizontal portions of the hard palate, the retromolar
pad, and the buccal shelf are examples of such areas.
11. In preparing overdenture abutments, it is important to re-
duce the crown-root ratio to prevent undue lateral stresses and to
provide ample room for artificial teeth.
12. For overdentures, sufficient attached gingivae should be
present around the abutments. The moving denture base should
not impinge on or cause strangulation of the tissue of the free gin-
gival margin.
13. The angle of emergence of the coping or attachment of an
overdenture abutment tooth should be compatible with gingival
health and hygiene maintenance.
14. Although retentive devices can enhance overdeuture reten-
tion, they may not be essential for successful patient care.
15. When available, canines are the most desirable teeth to
support overdentures.
16. The clinical crown length of an overdenture abutment
should be 2 to 3 mm above the proximal gingival margin to avoid
migration of the gingival tissue.
17. For overdenture abutments, the tooth reduction on the la-
bial or buccal surfaces should be sufficient to allow esthetic posi-
tioning of the artificial teeth.
18. Overdenture abutments aid in providing support and sta-
bility to a prosthesis.
19. Overdenture abutments provide a degree of tactile sense,
which aids proprioception.
20. Overdenture abutments assist in preserving alveolar bone.
C. Soft tissue management
1. Patients who are already using dentures should remove them
for a time before final impressions are made and before new den-
tures are placed.
2. Factors to consider in determining the length of time for
complete tissue rest include (1) the patient's age, (2) the condition
of the supporting tissue, (3) the length of time the prosthesis has
been worn continuously, and (4) the thickness of the mucoperios-
teum.
3. Before impressions are made of tissues that have been sup-
porting a removable prosthesis, the tissues should be returned to
a physiologic status through tissue conditioning, massage, and/or
complete rest.
4. Residual ridge resorption under complete dentures may alter
occlusal relationships, which can further hasten ridge resorption.
5. For overdenture abutments, periodontal health should be
established and maintained. Educating the patient in proper teeth
and denture maintenance is important. Daily, the patient should
clean the teeth under the denture and apply fluoride.
D. Impressions
1. There is a relationship between the requirements for an ad-
equate impression and the contemplated external form of the
prosthesis. Before the impression procedure is started, a concept
88
ACADEMY OF P R O S T H O D O N T I C S
of the completed denture border form should be developed. This
is determined from the diagnostic cast and by visual and digital
examination of the denture-bearing area, including the influence
of the tongue on the level of the floor of the mouth.
2. A maxillary preliminary impression should completely fill the
labial and buccal vestibules and extend posteriorly beyond the
hard palate and into the pterygomaxillary notches. A preliminary
mandibular impression should include the entire residual ridge
and the retromolar pad, and extend lingually into the floor of the
mouth including the retromylohoid fossa. The distobuccal exten-
sions should include the external oblique ridges, and should
approach the anterior borders of the rami.
3. Final impressions should record the entire denture founda-
tion area to be covered by the denture base.
4. The fovae palatinae are anatomic landmarks. They can be
used as one aid to determine the posterior limit of the maxillary
denture.
5. The location of the junction of the movable and immovable
soft palate is used to determine the posterior extension of a com-
plete maxillary denture.
6. The curved borders of the labial, buccal, and lingual areas of
final impressions represent the extension and contours to be
reproduced in the processed prosthesis.
7. Areas of the impression tray t h a t may exert excessive pres-
sure on the denture foundation area should be determined and re-
lieved before an impression is made.
8. Impressions of edentulous arches should record the form of
healthy tissue at rest. They should extend to the physiologic limit
of border tissues in order to maintain a border seal and to assure
t h a t functional stresses are distributed over the greatest area of
support.
9. The complete denture final impression provides for intimate
tissue contact and border seal of the denture base, excluding in-
gress of air between the denture base and soft tissue. These phys-
ical factors permit atmospheric pressure to serve as the primary
physical factor in complete denture retention.
10. Selective pressure complete denture impressions permit the
recording of certain anatomic regions with minimal pressure and
other areas with mild pressure. This promotes less positive contact
of the denture base with anatomic regions that are not ideal
stress-bearing areas because of the friable nature of the mucosa or
the susceptibility to pressure-induced resorption.
E. Casts
1. Complete denture impressions should be boxed before pour-
ing master casts.
2. Type II dental stone has adequate physical properties for
complete denture casts.
3. Complete denture casts should have a clearly defined land
area.
F. Record bases, occlusion rims, and m a x i l l o m a n d i b u l a r
records
1. The incisal length of maxillary occlusion rims should be es-
tablished after the desired contour of the facial surfaces has been
set.
2. To prevent displacement of complete denture bases, it is
particularly important that the centric relation record be made
with a minimum of closing pressure.
3. Mechanical recording devices are more accurate when
(a) Neuromuscular control is good
(b) The residual ridges are ample
(c) The soft tissues are not highly displaceable
4. Methods for recording maxillomandibular relationships in-
clude
(a) Interocclusal records
(b) Mechanical devices
(c) Chew-in techniques
(d) Cephalometric radiographs
VOLUME 73 NUMBER 1
ACADEMY OF PROSTHODONTICS
5. Recording centric relation at the correct vertical dimension
of occlusion is one of the most important factors in complete den-
ture construction.
6. Centric relation is a desirable position to record and transfer
to an articulator during the fabrication of complete dentures.
7. Centric relation should be recorded at the correct vertical di-
mension of occlusion unless casts ar e mounted on the transverse
horizontal hinge axis on an appropriate articulator.
8. Before the centric relation record is made, the vertical
dimension of occlusion usually should be established.
9. Centric relation records should be verified regardless of the
posterior tooth form t h a t is used.
10. A face-bow is important when any change in the vertical di-
mension of occlusion is anticipated during therapy. Such changes
in vertical dimension include
(a) Compensation for interocclusal record thickness
(b) Excursive movements when cusped teeth are used
(c) Alterations in the vertical dimension of occlusion, includ-
ing occlusal adjustment
11. In determining posterior reference points for a face-bow
record, an anatomic average transverse horizontal axis is generally
acceptable for tissue- or tooth-tissue-supported prostheses.
G. Complete denture occlusion
1. To prevent deflective occlusal contacts, the cuspal inclines of
artificial teeth may require selective alteration.
2. A universally accepted concept of articulation and occlusal
form for complete dentures has yet to be scientifically established.
Several concepts for eccentric occlusal relationships may be used
with success.
3. A reduction in the vertical dimension of occlusion as a result
of either a loss of supporting tissues or wear of teeth shifts the
mandibular jaw position and occlusion anteriorly.
4. The vertical and horizontal jaw relations of natural teeth
should be evaluated before immediate denture service is initi-
ated.
5. When a vertical overlap of anterior teeth is necessary, suffi-
cient horizontal overlap is desirable to prevent tooth interference
during speaking and masticating.
6. The occlusal plane should be located according to mechani-
cal requirements for (1) denture stability, (2) efficient mastication,
(3) preservation of supporting structures, (4) anatomic landmarks,
(5) esthetics, and (6) phonetics.
7. The stability of the denture bases supporting artificial teeth
is important in maintaining a previously created balanced articu-
lation.
8. Bilateral eccentric contact can be developed with anatomic or
nonanatomic posterior teeth.
9. To evaluate changes in occlusion caused by processing, com-
plete dentures may be returned to the articulator before removal
from the cast.
10. Incorrect vertical dimension of occlusion increases the po~
tential for bone resorption beneath immediate or conventional
complete dentures.
11. Malocclusion increases the potential for ridge resorption in
the prosthodontically restored edentulous patient.
12. Occlusal discrepancies may result from the dimensional
changes of materials used to process resin dentures.
13. Malocclusion often occurs after residual ridge resorption:
Complete dentures should not be relined until such malocclusion
has been corrected.
14. Proper use of a semiadjustable articulator is advantageous
in complete denture construction.
15. An adequate occlusal scheme can be developed for complete
dentures on a sere:adjustable articulator.
16. Before single complete dentures are made, the opposing
natural teeth should be restored or recontoured to favorable
occlusal form.
J A N U A R Y 1995
THE JOURNAL OF PROSTHETIC DENTISTRY
It. Try-in and verification procedures
1. Any treatment sequence for complete dentures should in-
clude a try-in of artificial teeth with stable denture bases to eval-
uate the vertical and horizontal maxillomandibular relationships,
esthetics, and phonetics. The patient and, when possible, a family
member or friend should participate in the evaluation.
2. Assessing the correct vertical dimension of occlusion before
all of the teeth are arranged on the denture base is difficult.
3. Enunciation is diagnostically more accurate with trial den-
tures than with wax rims.
4. Aging, physical limitations, previous dental history, and lack
of neuromuscular coordination may combine to render impossible
the absolute verification of maxillomandibular relationships.
5. Verifying accuracy of the vertical dimension of occlusion
should follow verification of centric relation and securing eccentric
records.
6. After the try-in appointment, teeth should be repositioned
for optimal contacts in the centric relation and eccentric positions.
The dentist should take care not to alter the appearance of the
dentures.
I. Complete denture materials
1. To minimize distortion, previously processed acrylic resin
denture bases should not be heated above 165 ~ F.
2. Processed resilient denture base materials may be of value for
patients demonstrating persistent soreness and inability to wear
well-constructed dentures with hard resin bases.
3. Using porcelain teeth in complete dentures t h a t oppose nat-
ural teeth or gold restorations may cause undesirable wear of the
opposing teeth.
4. The dentist should understand the role of various denture
base materials and their influence on supporting tissues.
J. Esthetic considerations
1. In the arch, the relationship of artificial teeth to each other
affects the apparent size and color of individual teeth. Placing a
tooth more anterior in the arch creates an illusion of a lighter shade
and larger tooth. Placing the tooth more posterior in the arch cre-
ates an illusion of a darker shade and a smaller tooth.
2. The level of the occlusal plane in the mandibular premolar
area is usually at or slightly below the commissure of the lips.
3. Posterior teeth of a natural-appearing length should be used
whenever the interridge distance permits.
4. A common defect in facial appearance results from position-
ing the maxillary anterior artificial teeth too far palatally.
K. Initial placement
1. To correct occlusal discrepancies after initial adjustment of
the dentures' tissue surface, complete dentures should be re~
mounted to a semiadjustable or a fully adjustable articulator.
2. Mounting the completed restoration in an articulator with a
proven interocclusal record is an accurate method of developing
final mandibular position and occlusion. It is more accurate than
intraoral occlusal correction.
3. During the initial placement of complete dentures, the den-
tist should evaluate (1) border extensions, (2) border seal, (3) re-
tention, and (4) esthetic values.
Areas where the denture exerts excessive pressure on the den-
ture foundation area should be located and relieved.
4. When porcelain teeth have been ground during occlusal ad-
justment, their surfaces should be polished.
5. At the initial placement appointment, previous educational
efforts should be reinforced. The patient should receive verbal
and/or written instructions regarding the wearing and care of
dentures and cleansing procedures for the supporting tissues.
6. To maintain good tissue health, complete dentures should
be removed from the mouth for several hours during each 24-hour
period. The patient may prefer to leave dentures out during sleep.
7. For future reference, a record of the vertical dimension of oc-
clusion should be made at initial denture placement.
89
THE JOURNAL OF PROSTHETIC DENTISTRY
8. Patients should not be given removable restorations before
occlusal discrepancies are eliminated.
9. Instructions to overdenture patients must emphasize metic-
ulous daily cleansing of retained overdenture abutment teeth and
the importance of using nonacidulated fluoride daffy in the den-
ture over abutment teeth.
L. Care after placement
1. During the early wearing period of processed resin dentures,
some adjustments of the tissue surfaces should be expected.
2. Complete denture treatment should include provision for
adjustment appointments after initial placement of the dentures.
3. Complete denture patients should be examined at least an-
nually to determine the health of oral tissues and condition of
dentures. The importance of these factors should be stressed to
each patient.
4. Patients should be advised and reminded t h a t complete
dentures require periodic adjustment and eventually will require
modification, which may include relining or remaking to m a i n t a i n
proper tissue adaptation and occlusion.
5. When dentures are initially placed, and at subsequent
appointments, the dentist should emphasize adequate hygiene
maintenance of both the mucosa and the dentures.
6. Dietary recommendations for the patient during the adjust-
ment period are advisable.
7. The form of the denture-bearing area for complete dentures
continues to change throughout life.
8. Residual ridge resorption under complete dentures causes
malocclusion.
9. Patients should receive a careful explanation of the possible
deleterious effects of a complete maxillary denture opposed by
mandibular anterior natural teeth and a distal-extension remov-
able partial denture. The need for frequent examination, continu-
ing treatment when necessary, and removal of both dentures while
sleeping should be emphasized.
10. The proper relining of complete dentures requires skill and
meticulous care.
11. Altering the vertical dimension of occlusion should not oc-
cur during relining unless it is required to restore proper vertical
dimension.
12. Relining complete dentures must include restoring proper
occlusion. This may require a clinical remount procedure after the
reline and before the denture is seated.
13. The overdenture patient must be seen for regular, frequent
recalls to reevaluate and reinforce oral hygiene practices, correct
any new or recurrent periodontal problems, restore carious lesions,
and adjust the denture adaptation to the teeth and tissues.
M. I m m e d i a t e and interim restorations
1. For introducing patients to complete dentures, immediate or
transitional dentures are the desired method of treatment. They
should be constructed only after the patient has been informed of
the requirements of immediate denture service. Where indicated,
an interim or transitional partial denture may facilitate the
patient's adjustment to complete dentures.
2. Properly constructed and adjusted immediate dentures aid
the healing response of the denture-bearing tissues.
3. When teeth are extracted for placement of immediate den-
tures, unnecessary bone removal should be avoided.
4. Immediate denture treatment is time-consuming and exact-
ing.
5. After the immediate denture has been placed, the patient
should return to the dental office at stated intervals so t h a t border
extensions, occlusion, and tissue irritation can be evaluated and
needed corrections can be made.
6. The immediate denture or one that has been constructed
soon after extraction of the remaining teeth m u s t be maintained
with additions and subtractions for the entire healing period.
Eventually, relining, rebasing, or denture refabrication will be
necessary.
90
ACADEMY OF PROSTHODONTICS
7. Before definitive relining or secondary denture treatment,
the use of successive temporary relines for immediate complete
dentures is recommended. During the healing period, they main-
tain (1) support, (2) stability, (3) comfort, and (4) function.
8. When duplication of the arrangement of natural teeth is de-
sirable, the teeth should be removed from the cast one at a time
so that the remaining adjacent and contralateral teeth serve as
guides for positioning each artificial tooth.
9. The vertical and horizontal jaw relations established by the
natural teeth should be evaluated before implemention of imme-
diate denture service.
10. Because swelling and edema follow placement of immediate
dentures, malocclusion should be corrected after swelling and
edema have subsided.
11. In the interim immediate denture procedure, all remaining
teeth are usually extracted at denture placement.
12. An interim complete denture used during the healing period
has several advantages over the conventional immediate denture:
(a) Final impressions and jaw relation records for definitive
dentures are performed after healing.
(b) A wax try-in is possible for the definitive denture.
(c) The patient can retain the interim denture to serve in an
emergency.
13. An interim prosthesis may need to be relined or remade
shortly after placement to compensate for changes in the denture
foundation area.
14. In immediate denture treatment, the use of interim den-
tures for initial placement and during the healing period is recom-
mended. Better quality secondary dentures can be constructed on
completely healed supporting tissues.
15. Prior to beginning fabrication of a conventional immediate
denture, all posterior teeth are extracted except those necessary to
provide occlusal contacts adequate to maintain interarch distance.
16. A transparent surgical template may be used as a guide to
the amount of surgery required during placement of immediate
dentures.
VL Implant r e s t o r a t i o n s
A. Diagnostic information
1. The clinical evaluation of a patient requiring implant prosth-
odontic treatment should include dental, medical, and surgical
histories. Speech and psychologic testing may also be needed.
2. Unrealistic expectations may affect the prognosis in implant
patients.
3. Radiographic examination may require intraoral, panoramic,
cephalometric, and tomographic imaging techniques.
4. Age does not appear to be a factor in the success of dental
implants.
B. Diagnosis
1. Need for an implant-supported prosthesis should be estab-
lished as an alternative to conventional denture therapy.
2. Patients to be treated for endosseous dental implants should
have diagnostic casts articulated with a trial arrangement of arti-
ficial teeth on trial denture bases. A presurgical prosthodontic
evaluation analysis is essential for site, number, and position of the
implants.
3. The type of implant for use in a patient must be selected rel-
ative to the quality and quantity of osseous tissue available to
support the implant.
4. An analysis should be made of attached and nonattached
gingiva surrounding implant sites and consideration should be
given to the adequacy of attached gingiva at the permucosal site
of implant posts.
5. Prosthodontic treatment must be planned before implant
surgery.
C. Prognosis
1. The patient should be informed of benefits, risks, time, cost
of treatment, and alternative treatments.
VOLUME 73 NUMBER 1
ACADEMY OF PROSTHODONTICS
2. Meticulous sterile surgical techniques are essential to the
initial and long-term success of any dental implant system.
3. Alveolar bone surrounding osseointegrated implants has the
potential to maintain slower resorptive patterns than alveolar
bone supporting conventional tissue-borne prostheses.
4. Replacement teeth should not be arranged for appearance in
a position t h a t could cause an unfavorable force distribution and
compromise oral hygiene.
5. Future health changes could change the prognosis for sur-
vival of an implant restoration.
19. P r e r e s t o r a t i v e t r e a t m e n t
1. The oral structures, dentulous or edentulous, should be in a
state of optimal health.
2. Any systemic disorder must be recognized and evaluated rel-
ative to dental implant success.
3. Before proceeding with treatment, patient response to edu-
cational efforts should be assessed.
4. If an interdisciplinary team provides treatment, one mem-
b e r - u s u a l l y the restorative d e n t i s t - - m u s t supervise and direct
treatment.
E. P r o s t h o d o n t i c t r e a t m e n t
1. Dental implants may be classified as subperiosteal, endo-
dontic, endossteal, transosteal, intramucosal inserts, supraperi-
osteal or subperiosteal augmentation.
2. Fixed, removable, fixed-removable, and overdenture pros-
theses can be used with dental implants. The prosthesis must
match the implant capabilities.
3. Casts for diagnosis and/or custom implant design and fabri-
cation may be obtained by the following means
(a) Conventional intraoral impressions
(b) Surgical degloving followed by a bone impression
(c) Computerized axial tomography to produce a computer-
generated model
4. Direct impressions of the alveolar bone must be made with
nonirritating materials. All particles of impression material must
be removed from the bone surface and tissue after removal of the
impression.
5. A totally implant-supported prosthesis does not depend on
soft tissue for support. The impression needs only extend to
regions necessary for landmark identification.
6. An implant- and tissue-supported prosthesis uses soft tissue
areas for support. Therefore, an impression should be made
according to accepted principles for optimal support, extension,
and stability for tissue-borne prostheses.
7. It is the dentist's responsibility to design the implant-
supported restoration.
8. An immobile occlusal record base facilitates obtaining accu-
rate and verifiable maxillomandibular relation records.
9. Fixed, fixed-removable, removable partial, removable com-
plete dentures, and overdentures in implant dentistry have varied
occlusal requirements. Occlusion should be developed to reflect
the prosthodontic capabilities of the dentist, the available support,
and the needs of the patient.
10. Occlusal patterns t h a t direct forces to the regions selected
for stress distribution should be developed.
11. All implant-supported restorations should seat passively
over implant abutments.
12. Overdentures supported completely by implants may not
require border extensions or palatal coverage to the same extent
as conventional complete dentures.
13. The patient must be informed of the need for continued
regular maintenance.
14. Diligent home care is necessary with periodic professional
maintenance.
F. M a t e r i a l s a n d d e v i c e s
1. When planning the prosthesis, the dentist should be aware of
the implant type, number, design, and stress distribution to the
surrounding tissues.
JANUARY 1995
THE JOURNAL OF PROSTHETIC DENTISTRY
2. Materials and techniques must be biocompatible.
G. I n t e r i m r e s t o r a t i o n s
1. Immediate restorations on endosseous implants may or may
not be placed depending on the style of implant and philosophy of
use.
2. Interim restorations may consist of removable complete
dentures, removable partial dentures, or fixed prostheses depend-
ing on the implant supported and the system used.
3. Interim dentures for patients with osseointegrated dental
implants should be periodically relined with soft lining material
during the healing period to prevent trauma to the implant sites.
MATERIALS AND DEVICES
L Articulators
1, An articulator is a mechanical device that represents tem-
poromandibular joints and jaw members. Maxillary and mandib-
ular casts may be attached to articulators. Some or all mandibular
movements may be simulated.
2, The ideal articulator should be capable of reproducing all the
patient's jaw movements during function and parafunction. It
should maintain the mounted relationship of the opposing casts.
3. The use of an articulator is essential in most types of prosth-
odontic care.
4. An articulator is no more accurate in reproducing mandibu-
lar movements than the records used to adjust the instrument.
5. Articulator types can be classified as simple hinge, average
value, sere:adjustable, fully adjustable, and fossae molded:
6. Simple hinge articulators can be accurate in centric occlusion
when casts are mounted at the correct vertical dimension of occlu-
sion. Eccentric positions cannot be reproduced. Changes in the
vertical dimension of occlusion accomplished on the articulator
invalidate the centric occlusion.
7. Average value articulators have the same limitations as sim-
ple hinge articulators. However, they will permit minor changes in
vertical dimension of occlusion if a transverse horizontal-axis
face-bow is accepted by the articulator and utilized. Eccentric po-
sitions only approximate the patient's eccentric positions.
8. Semiadjustable articulators used with a kinematic face-bow
and eccentric records allow (1) centric relation records to be
mounted at an increased vertical dimension; (2) minor changes in
vertical dimension; and (3) closer approximation of the patient's
mandibular movement at the end points of eccentric movement
t h a n when an average value articulator is used.
9. When provided with the proper kinematic records and pro-
gramming, a fully adjustable articulator or fossae molded articu-
lator will encompass all of the features of the semiadjustable ar-
ticulator. It will also closely approximate the patient's mandibu-
lar movement on all points along its eccentric movements.
10. Casts mounted in an articulator provide important data to
analyze, diagnose, and plan treatment.
11. Verification of the relationship of the casts mounted in the
articulator is a prerequisite to developing accurate occlusal con-
tacts of completed restorations.
12. The adjustable guidances of an articulator should permit
alteration to harmonize with the recorded and/or anticipated
mandibular movements.
13. The anterior guide of an articulator should be adjustable
and/or have a provision for custom guide fabrication.
14. A face-bow record should be used for mounting the maxil-
lary cast on an articulator that will accept an axis transfer.
15. Before a prosthesis is finalized or luted in place, an occlusal
scheme developed on any articulator should be clinically evaluated
in the mouth.
16. When extensive fixed occlusal restorations are planned, a
fully adjustable articulator or technique giving equivalent accu-
racy is desirable.
17. The dentist should know the limitations of the articulator
being used and how to compensate for them.
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18. A third point of reference is important in a face-bow trans-
fer because it
(a) Permits subsequent remounts of the maxillary cast in the
same position
(b) Permits use of previously recorded condylar path settings
(c) Allows the maxillary cast to be oriented in the articulator
in the same relation to the horizontal axis as the maxillary
arch is to a Similar plane selected on the patient
(d) Permits the application of anatomic average values as
condylar path settings when such settings are adequate
INTERIM RESTORATIONS
1. An interim restoration is a dental prosthesis used for a short
interval for esthetics, mastication, occlusal support, convenience,
or to condition the patient to accept definitive prosthodontic
therapy.
2. Some temporomandibnlar joint symptoms may be alleviated
by properly constructed interim restorations.
3. Tissue-conditioning materials placed on the tissue surface of
surgical prostheses can compensate for tissue changes after
surgery.
4. Transitional removable partial dentures may be used to fa-
cilitate osseous healing and to help maintain the vertical dimen-
sion of occlusion after posterior teeth have been removed.
5. Interim restorations may be desirable before placement of
endosseous implants
(a) To maintain function and appearance during the post-
surgical healing phase
(b) To aid in presurgical planning of the location and angu-
lation of implants
6. Interim restorations should be used in fixed prosthodontics
when the vertical dimension must be restored and dental esthetic
requirements determined.
7. An interim prosthesis may be constructed to aid in stabiliz-
ing the dentition during periodontal treatment.
8. Interim restorations should meet all restoration guidelines
for periodontal health, esthetics, and function. They should stabi-
lize the occlusion and position of the remaining teeth. Where lost
vertical dimension of occlusion is to be restored, the interim res-
toration can verify this occlusal dimension so it can be restored in
harmony with oral facial function.
A U X I L I A R Y P E R S O N N E L , WORK
AUTHORIZATION, AND LABORATORY
UTILIZATION
A. A u x i l i a r y personnel
1. Clear, concise communication among all members of the
dental health team enhances the quality of the dental service t h a t
a patient receives.
2. Auxiliary personnel may help the dentist obtain diagnostic
information for treatment planning purposes.
3. Delegating specific procedures to qualified auxiliaries is ac-
ceptable where legally permissible. However, the dentist is re-
sponsible for treatment within the framework of liability estab-
lished by the governing jurisdiction.
4. The dentist is responsible for the quality of the completed
prosthesis even when parts of the fabrication are delegated to a
dental laboratory.
5. The dental technician is a valuable member of the prosth-
odontic team. Communication between the technician and the
dentist enhances patient's treatment.
6. To improve the quality of the finished restorations, the den-
tal technician's skills and training should be recognized and prop-
erly used as an adjunct.
7. The dentist is required to use auxiliary personnel in compli-
ance with state dental practices.
8. The dentist should be in the office when auxiliary personnel
perform intraoral procedures as permitted by state laws.
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ACADEMY OF PROSTHODONTICS
9. The dentist should recognize special needs of patients and,
when necessary, refer them to qualified specialists for treatment.
10. Cooperation and communication between the dentist and
the oral and maxillofacial surgeon is essential for preprosthetic
surgery procedures.
11. Prosthodontists, dental assistants, and dental technicians
should prevent contagious disease contact and transmission. They
should be immunized. Instruments, impressions, and casts should
be sterilized; environmental surfaces should be disinfected. Gloves,
protective ey e wear, and facemasks should be used.
12. When indicated, a dentist, physician, or nutritionist should
provide the patient with nutritional advice.
B. Specific to maxillofacial prosthetics
1. A prosthetist, under the supervision of a prosthodontist, may
make facial prostheses in contact with the patient.
C. With authorization and laboratory utilization
1. A properly executed work authorization can be an effective
way for the dentist to communicate with the dental laboratory
technician.
2. All work delegated to a commercial dental laboratory should
be accompanied by a detailed written work authorization that
complies with the applicable state dental laws.
3. The dentist's specific work authorization is essential to qual-
ity control during the laboratory phase of making prostheses.
4. The dentist should provide a completed work authorization
form t h a t states the specifications of materials that will best meet
the needs of the patient. When artificial teeth are involved, the
specification should include manufacturer, material, shade, mold,
and design.
5. Accurate interocclusal records are essential to mount casts
properly in an articulator. Accurate interocclusal records are the
dentist's responsibility.
6. The dentist must provide the laboratory with adequate diag-
nostic casts, mounted casts or (as a minimum) complete-arch casts
with a stable interocclusal record. Master casts should have dies
trimmed and finish lines marked by the dentist.
7. Removable prostheses should be returned to the dentist for
wax trial evaluation before they are completed.
8. The dentist is responsible for selection and final position of
artificial teeth.
9. The flasking of a removable prosthesis in artificial stone or
other suitable material should be done in sections to facilitate
separation of the prosthesis from the investment material.
10. When a fixed restoration is to be placed in conjunction with
a removable partial denture, the design of both should be coordi-
nated by designing the restorations with the use of a diagnostic
cast.
11. The dentist should request that the metal ceramic frame-
work be waxed to full contour as directed by diagnostic waxing and
be cut back to allow proper veneering control.
12. Whenever the cast metal portion of any prosthesis is com-
plicated, a framework try-in should be requested. Framework try-
ins of extensive ceramic restorations should be routine.
13. Direct dentist-technician communication is necessary in
working with ceramic restorations. An appropriate method of
communication should be used to facilitate final shading and
staining.
LEGAL C O N S I D E R A T I O N S
A. Basic to all prosthodontics
1. The laws of each jurisdiction are different and, although this
is written with generic law in mind, laws t h a t apply to specific ju-
risdictions may be obtained from a local attorney.
B. The dentist-patient relationship
1. Contract law governs the relationship of the dentist and the
patient.
2. A contract is an agreement between competent parties to
perform, or not to perform, some legal act.
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ACADEMY OF PROSTHODONTICS
3. Except in special situations, usually not related to the den-
tist-patient relationship, the terms of a contract need not be in
writing to be enforceable.
4. The written contract serves as evidence that an agreement
between the parties was reached.
5. The terms of a contract may be expressed or implied.
6. Usually expressed terms include
(a) The fee
(b) Nature of the treatment to be performed
(c) Time in which the treatment is to be completed
(d) Payment arrangements
(e) Other specific items)
7. There are many additional implied terms (duties) that attach
to the doctor-patient relationship.
8. In jurisdictions in which cases have attempted to attach im-
plied warranties of fit and satisfaction, the courts have ruled
against such warranty.
9. The courts have consistently held that the fee paid for the
fabrication of a prosthesis is for the service required to complete
it and not for the physical prosthesis. However, guarantees m a d e
by the dentist would constitute an express term in the contract.
10. Unwarranted claims about the outcome of care that could be
interpreted as guarantees are unethical and in some jurisdictions
illegal.
11. Guarantees may result in loss of a suit based upon breach
of contract rather than on malpractice.
12. In a breach of contract suit, negligence need not be shown.
13. In many jurisdictions, unless the care provider makes an
express guarantee, breach of contract suits brought against health
providers are held to the same rules of law as suits of malpractice.
14. Many suits alleging malpractice are initiated because the
dentist brought an action against the patient to collect the fee.
15. There are times when a patient, dissatisfied with the service,
demands the return of the fee, in part or in whole, paid to the den-
tist. Failure to comply with the patient's request may result in the
patient initiating a suit against the dentist. To avoid such an event,
the dentist may elect to comply with the demand. However, before
any of the fee is returned, the dentist should require the patient
to sign a waiver of claims for prior acts. The waiver effectively
protects the dentist from a suit brought based on services provided
before the waiver was executed.
C. The s t a n d a r d of c a r e
1. In malpractice cases, the standard of care to which courts
hold dentists requires that they use the same degree of knowledge,
education, and training that a reasonably prudent dentist would
provide in the same or similar community.
2. Dentists who hold themselves out as specialists are generally
held to the standard of care of other specialists in the same field.
Thus, generalists who provide the same service are held to a lesser
standard of care. This double standard to which practitioners in
the community are held is the trend in many jurisdictions. In ef-
fect, there is a move by the courts to apply a national standard of
care to board certified specialists.
3. In general, because of rules of evidence, it is difficult to use
texts, guidelines of professional organizations, or what is taught in
a dental school as a means of establishing the standard to which
a defendant dentist will be held.
4. Consistent with the definition of the standard of care,
specialists usually are held to the standards of other specialists,
and general practitioners are usually held to the standards of other
general practitioners.
5. If one holds oneself as a specialist, although a generalist, the
courts are likely to apply the standards of a specialist.
6. Another risk for the generalist (depending on the quality of
treatment provided) is that if it can be shown that other general-
ists in the same community would have referred the patient to a
specialist, not having made the referral could constitute negli-
gence.
JANUARY 1995
THE JOURNAL OF PROSTHETIC DENTISTRY
7. Generally, it is desirable to limit treatment to aspects of den-
tistry in which the dentist is qualified and competent. Dentists
should make appropriate referrals on a timely basis, and maintain
their skills and knowledge consistent with advances in their field
of practice.
D. C o n s e n t
1. It is firmly established that a doctor who treats a patient
without informed consent may be liable for damages, even if the
treatment benefitted the patient.
2. In the landmark case of Canterbury vs. Spence, decided in
1972, the court indicated that consent must be informed to be
valid. Guidelines were established by which to judge whether the
consent was truly informed.
3. During the past decade, most courts have adopted the Can-
terbury view, either in whole or in part.
4. The question that remains is: How much must the patient be
told for the consent to meet the test of being informed? The states
are divided on this issue. The traditional standard of informed
consent determines by expert testimony what other practitioners
in the same community disclose to their patients when faced with
a similar treatment. The defendant practitioner is held to that
measure of disclosure.
5. Another standard of informed consent is the "the profes-
sional community." There are two divergent views expressed by
the courts using this standard: the objective test and the subjec-
tive test. In the former, the measure is: How much would any rea-
sonable person have to be told to make an intelligent decision? In
the latter: How much should the specific patient be told?
6. Much of the problem of informed consent centers around
disclosure of risks.
7. In jurisdictions that adhere to the reasonable person stan-
dard, the general rule is that risks that are "material" should be
disclosed.
8. A material risk is defined as one that may influence the pa-
tient's decision.
9. A legislature may adopt any option to define informed con-
sent. As an example, New York, by statute, chose the professional
community standard.
10. Many courts have distinguished between total lack of con-
sent and inadequate disclosure in obtaining consent. The former
may be considered assault and battery. In the latter, the dentist
is negligent for failing to obtain informed consent.
11. In an emergency, where immediate care must be provided
to protect the health or life of an injured person, and where con-
sent could not be obtained, consent is implied by law.
12. Documentation of consent, if it was obtained, plays a major
role in the outcome of a legal procedure.
13. The documentation that consent was obtained depends on
the mode of practice by the dentist.
14. In general, the more invasive the procedure and the
greater risk to the patient, the more documentation becomes
important.
15. Consent may range from a note made on the patient's record
to a note made on the record initialed by the patient. Consent may
also be obtained by having the patient sign a separate form. A
s i g n e d copy is placed in the patient's record folder.
16. The dentist must weigh the legal risks against the resources
of the practice in time, personnel, and effort in documenting that
consent was granted.
17. When faced with decisions to which risks may be attached,
the practitioner should, before any action is taken, make an "in-
formed decision." Elements that enter into the decision-making
process should include legal issues, ethical issues, and the benefits
a n d risks to the patient.
E. P a t i e n t r e c o r d s
1. In some jurisdictions, the law requires that accurate records
of the diagnosis and patient treatment be maintained as part of
care.
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THE JOURNAL OF PROSTHETIC DENTISTRY
2. In the eyes of the law, good records are as important in pa-
tient care as the diagnosis and treatment.
3. Failure to keep accurate records may result in penalties im-
posed by the state
(a) If the requirement to maintain records is mandated by
law
(b) If there is a negligence finding by a court in a civil suit
brought by a patient
(c) If a malpractice suit is lost because the defendant-dentist
was unable to document the care provided
4. Entries on the patient's treatment record may become pub-
lic information. The dentist should keep in mind that the record
may eventually be seen and subject to review by the patient's at-
torney, a judge, and a jury.
5. If the records are required for the defense of an allegation of
malpractice, they should be kept indefinitely for complete protec-
tion.
6. A reasonable rule of thumb is to retain records of adults for
10 years after the last treatment visit.
7. In the case of minors, the records should be kept for 10 years
after they reach majority.
8. Except when acting under the order of court, the dentist
should never part with the original record, radiographs, consulta-
tion reports, or any other document relating to care of a patient.
9. Entries in the record should be made in black ink or ballpoint
pen.
10. Entries should be initialed or signed in offices where more
than one person is permitted to write on patients' records.
11. Errors should not be blocked out so they cannot be read.
12. A single line should be drawn through the error and the word
error written above. The correction should be made on the next
available line.
13. What does not belong on the patient's record is sometimes
as important as what should be on it. Subjective notes about the
patient's mental state should be avoided.
14. In many jurisdictions, the patient may have access to den-
tal records. Dentists who are sued should not note on the treatment
record conversations with any attorney or insurance company
representatives. Such notes should be placed in a separate file.
15. If an attorney request the records of a patient, the dentist,
before complying, should make certain that the attorney includes
in the demand a properly executed release signed by the patient.
16. It is best not to include financial information on the treat-
ment record. Such data should be kept separately.
17. T h e d e n t i s t should never t a m p e r w i t h t h e records. F r a u d
m a y be s u s p e c t e d if t r e a t m e n t records a p p e a r to have been tam-
p e r e d with.
18. The patient's record is a legal document.
F. Associates and employees
1. In partnership practice, each innocent partner may be held
accountable for the negligent act of any other partner. When one
or more dentists appear to be partners, although they are not, they
may be treated by the courts as if they were partners and may be
held jointly or severally liable for the negligent act of one.
2. Corporate practice usually relieves an innocent shareholder
from liability for the negligent acts of other shareholders. Only the
negligent individual and the corporation may be held liable.
Treatment that has begun must be completed.
3. An employer is liable to an injured party for the negligent acts
of an employee.
4. A dentist's employee becomes the dentist's agent in dealing
with patients.
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ACADEMY OF PROSTHODONTICS
5. When a hygienist, assistant, or secretary-receptionist makes
assurances to a patient regarding the treatment to be provided by
the employer-dentist, the dentist is bound by such assurances.
6. Employees should be informed of the responsibilities that
flow from their relationship with their employer and cautioned
about statements made to patients.
G. Managing difficult situations and issues of abandon-
ment
1. There are situations in which discontinuing treatment is the
only reasonable alternative to predictable failure in care, for
example, when the patient fails to
(a) Cooperate in the care
(b) Keep appointments
(c) Live up to financial agreements
If the dentist cannot function effectively under such circum-
stances, the patient should be so informed.
2. To avoid being found guilty of abandonment, the courts have
provided health practitioners with the following guidelines:
(a) Treatment should not be discontinued when the health of
the patient is placed at risk.
(b) The patient should be given adequate time to secure the
services of a substitute dentist.
(c) The patient must be assured that you will cooperate with
the substitute dentist in the care of the patient.
(d) Copies of all records and radiographs relating to the pa-
tient's treatment should be made available to the substi-
tute dentist upon request.
3. In notifying the patient of an intention to discontinue treat-
ment, it should be remembered that it is in the patient's best in-
terest and that the patient should be advised to seek the services
of another dentist.
4. After telling the patient of a decision to discontinue treat-
ment, the dentists should send a certified letter with return receipt
requested. The letter should state what the patient was told and
assure cooperation with the substitute dentist.
5. It is best to let the patient select the new dentist.
REFERENCES
1. The Academy of Denture Prosthetics. Principles, concepts, and prac-
tices in prosthodontics. J PROSTHETDENT 1959;9:528-38.
2. The Academy of Denture Prosthetics. Principles, concepts, and prac-
tices in prosthodontics. J PROSTHETDENT 1960;10:804-6.
3. The Academy of Denture Prosthetics. Principles, concepts, and prac-
tices in prosthodontics. J PROSTHETDENT 1963;13:283-94.
4. The Academy of Denture Prosthetics. Principles, concepts, and prac-
tices in prosthodontics--1967. J PROSTHETDENT 1968;19:180-98.
5. The Academy of Denture Prosthetics. Principles, concepts, and prac-
tices in prosthodontics--1977. J PROSTHETDENT 1977;37:204-21.
6. The Academy of Denture Prosthetics. Principles, concepts, and prac-
tices in prosthodontics--1982. J PROSTHETDENT 1982;48:467-84.
7. The Academy of Denture Prosthetics. Principles, concepts, and prac-
tices in prosthodontics--1989. J PROSTHETDENT 1989;61:88-109.
8. The Academy of Denture Prosthetics. Glossary of prosthodontic terms.
J PROSTHETDENT 1994;71:41-112.
REPRINTS
Reprints of the eighth edition of the Principles, Concepts, and
Practices in Prosthodontics are available from the Education and
Research Foundation of Prosthodontics. Send to Dr. Clifford Van
Blarcom, 5350 West 94th Terrace, Suite 205, Prairie Village, KS
66207-2572.
VOLUME 73 NUMBER 1