SECTION EDITOR

Principles, concepts, and practices in prosthodontics-1989

Academy of Denture Prosthetics

PREFACE TO THE SEVENTH EDITION The first study was prepared in 1957 under the leadership
This edition is the latest. of a continuing effort by the of Drs. Luzerne G. Jordan, Frank M. Lott, and Russell W.
Academy of Denture Prosthetics to update the principles, Tenth.’ ‘The five successive publications were under the
concepts, and practices in prosthodontics. auspices of fellows of the Academy: Drs. George Hughes,
The seventh edition is a major revision with input from 11 0. M. Dresen, Victor H. Sears, Leroy E. Kurth, S. Howard
organizations in contrast to three for the sixth edition. Sug- Payne, Chester K. Perry, Richard Kingery, Victor L. Steffel,
gestions for revision of existing statements and for new Arthur E. Aull, 0. C. Applegate, Davis Henderson, Henry E.
statements were received from the Academy of Denture Ebel, I. Kehneth Adisman, Charles Bolender, and Jack
Prosthetics, the American Academy of Crown and Bridge Preston.2-6
Prosthodontics, the American Academy of Esthetic Den- Members of the Principles, Concepts, and Practices Com-
tistry, American Academy of Implant Dentistry, American mittee for the seventh edition were Dr. Dale E. Smith,
Academy of Maxillofacial Prosthetics, American Academy of Chairman, Dr. Arthur 0. Rahn, and Dr. Ned B. Van Roekel.
Periodontology, the American College of Prosthodontists, Drs. Louis J. Boucher, Francis V. Panno, and George E.
the Midwest Academy of Prosthodontics, Northeastern Smutko were consultants to the committee.
Gnathological Society, the Northeastern Prosthodontic So- RESPECTFULLY SUBMII-TED BY:
ciety, and the Pacific Coast Society of Prosthodontists. Dr. Dale E. Smith, Chairman
Some organizations, such as the Academy of Denture PRINCIPLES, CONCEPTS, AND PRACTICES COMMITTEE:
Prosthetics, sought input from each member; others worked Louis J. Boucher, Francis V. Panno, Arthur 0. Rahn,
by committee. All suggestions were edited by the Commit- George E. Smutko, Ned B. Van Roekel, Dale E. Smith
tee of the Academy of Denture Prosthetics before submis-
sion to the participating organizations for revision and PRINCIPLES, CONCEPTS, AND
refinement. Finally, these suggestions were again edited and PRACTICES IN PROSTHODONTICS-1989
submitted to the membership of the Academy of Denture
Prosthetics for approval. A minimum of 85% affirmative Guide and index to PCP statements
Definitions 88
votes by voting fellows was required for publication of the Gathering diagnostic information 89
statements. Diagnosis and treatment planning 89
The Academy of Denture Prosthetics is indebted to all of Prognosis 90
the participating organizations. In particular, the suggestion Prerestorative treatment 90
for the new format was developed by the American College Treatment of oral structures 90
Reevaluation and refinement of treatment plan 91
of Prosthodontists. In addition, the section on Legal Con- Prosthetic treatment 91
siderations was developed by Dr. Burton R. Pollack, who is I. Basic to most areas of prosthodontics 91
an attorney and dentist, from the School of Dental Medicine, II. Fixed partial dentures 94
State University of New York, Stony Brook, N. Y. III. Removable partial dentures 96
Support for the committee activities came from the Edi- IV. Maxillofacial prosthetics loo
V. Complete dentures 102
torial Council of the Journal of Prosthetic Dentistry, the VI. Implant restorations 105
Federation of Prosthodontic Organizations, and the Educa- Materials and devices 106
tion and Research Foundation of Prosthodontics. Each con- I. Articulators 106
tributing organization funded its own committee activities. Interim rest.orations 107
The purposes of the Principles, Concepts, and Practices in Auxiliary personnel and work authorization 107
Legal considerations 107
Prosthodontics-1989 are:
DEFINITIONS’
1. To provide for the practicing prosthodontist and generalden- 1. Prosthodontics is the branch of dentistry pertaining to the
tist a reference of principles, concepts, and practices that are restoration and maintenance of oral function, comfort, appearance,
currently accepted by leading prosthodontists and health of the patient by the restoration of natural teeth and/or
2. To provide a current standard of acceptable practice standards the replacement of missing teeth and contiguous oral and maxillo-
in the absence of scientific research to prove all principles, facial tissuel3 with artificial substitutes.
concepts, and practices in prosthetic dentistry 2. Fixed prosthodontics is the branch of prosthodontics con-
3. To assist predoctoral and postdoctoral students of prosthodon- cerned with the replacement and/or restoration of teeth by artificial
tics, particularly the graduate student, in assessing the value of substitutes that are not removable from the mouth.
various ideas that are presented during their educational 3. Removable prosthodontics is the branch of prosthodontics
experience concerned with the replacement of teeth and contiguous structures

88 JANUARY 1989 VOLUME 61 NUMBER 1

PRINCIPLES. CONCEPTS, AND PRACTICES IN PROSTHODONTICS
for edentulous or partially edentulous patients by artificial substi-
tutes that are removable from the mouth.
4. Maxillofacial prosthetics is the branch of prosthcdontics con-
cerned with the restoration and/or replacement of stomatognathic
and associated facial structures by artificial substitutes that may or
may not be removable.
5. Implant prosthodontics is the phase of dentistry concerning
the restorative phase following implant placement.
GATHERING DIAGNOSTIC
INFORMATION
1. At the first appointment, the patient should be encouraged to
describe previous medical and dental experiences. To interpret the
patient’s concerns, the dentist must be attentive and record the pa-
tient’s concerns and expectations.
2. A diagnosis may require information from one or more of the
following sources: medical and dental histories, a clinical examina-
tion, radiographic surveys, diagnostic casts, consultations with
other health practitioners, and tests that may include pretreat-
mentprocedures such as a diagnostic prosthesis, trial prosthesis,
and surgery.
3. A standardized examination form for recording data may be
used during the examination. The oral cavity, visible pharynx,
paraoral structures, and associated lymph nodes should be exam-
ined. Patients with special needs may require additional diagnostic
procedures such as speech analysis, psychosocial assessment, oc-
clusal analysis, diagnostic sounding procedures, sialography, photo-
graphs, and other testing mechanisms.
4. A list of questions about prior dental experience may guide the
patient to provide information not otherwise elicited in an open-
ended discussion.
5. The dentist should consider the patient a potential carrier of
contagious disease and follow current guidelines of the American
Dental Association (ADA) and the U.S. Centers for Disease Control
during patient care.
6. For patients with orofacial defecta, a psychosocial evaluation
may be a valuable aid for diagnosis and treatment plan development.
7. All patients with natural teeth should receive a thorough, sys-
tematic periodontal examination including a clinical and radio-
graphic examination, pocket depth probing, and an evaluation of
periodontal status.
DIAGNOSIS AND TREATMENT
PLANNING
1. Diagnosis is the determination of the nature of a disease.
2. In-depth knowledge of anatomy, embryology, histology, phys-
iology, microbiology, pathology, psychology, biochemistry, pharma-
cology, and the physiology of oral function are factors that improve
diagnostic capabilities.
3. The dentist should identify and record any active disease pro-
cess and any defects created by disease. When indicated, the den-
tist should refer the patient to appropriate professionals for further
diagnosis or treatment.
4. Maxillofacial defects may be congenital, acquired, or develop-
mental.
5. Structures that provide valuable support, stability, and retenr
tion for a maxillofacial prosthesis should be preserved.
6. Normal growth patterns should be understood so that devia-
tions can be recognized and evaluated.
7. Mechanisms of the healing process of the oral and perioral hard
and soft tissues should be understood.
8. Inflammation may cause changes in the appearance and func-
tion of the oral mucosa.
9. Assessment of the following information is essential to the pe-
riodontal aspects of the 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
THE JOURNAL OF PROSTHETIC DENTISTRY
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
10. Exploratory surgical procedures should be referred to the ap-
propriate surgeon.
11. Drug effects and interactions must be understood by both
patient and dentist.
12. The oral mucosa is altered under a removable denture that
has been worn.
13. Bruxism may produce destructive changes in the supporting
tissues of removable dentures.
14. Because a favorable response to loading by a prosthesis has
been observed in both dense and porotic bone, bone density as seen
radiographically does not always indicate a response to additional
loading.
15. Bone resorption may be caused by many factors.
16. Aging causes changes in body tissues, organs, and functions,
which may affect patient response to a prosthesis.
17. Dimensional loss of the bony foundation supporting dentures
may lead to loss of the vertical dimension of occlusion.
18. The determination of the vertical dimension of occlusion is
generally a matter of judgment. Commonly used methods and
guidelines include the following:
(a) A measurement of 3 mm less than physiologic rest dimen-
sion
(b) An evaluation of the closest speaking space
(c) Proprioception or choice by patient
(d) Swallowing on soft wax cones
(e) Relative parallelism of ridges
(f) General appearance of the midface profile
19. The vertical dimension of rest is a postural position that is
subject to change.
20. A record of the maxillomandibular relationship when the
mandible is in its terminal hinge position is considered a necessary
component of a comprehensive diagnosis.
21. Altering the vertical dimension of occlusion requires critical
judgment. When an existing vertical dimension is to be altered, a
trial period at the new position may be used to ascertain that the new
position is physiologically acceptable.
22. In maximum intercuspation, all posterior teeth should con-
tact simultaneously. Deflective occlusaI contacts may cause altered
mandibular positions.
23. The occlusion of any patient that was established by pros-
thodontic procedures should be periodically reevaluated.
24. Correctly mounted diagnostic casts usually are necessary for
diagnosis and treatment planning.
25. The treatment planning, mouth preparation, and design of
removable partial dentures are professional responsibilities to be
accomplished by the dentist before the master casts are made and
given to a dental technician or dental laboratory for fabrication of
a framework.
26. The dental surveyor assists in contour analysis of hard and
soft tissues of the dental arch.
27. Criteria for selection of 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
(i) Occlusal relationships
89

(k) Crown contour
(1) Plaque control
(m) Impending functional demands
28. Treatment planning procedures for patients who are to be
treated with biocompatible dental implants should include diag-
nostic casts articulated with a trial arrangement of artificial teeth on
trial denture bases. A presurgical prosthodontic diagnosis is essen-
tial for site location and proper angle of implant placement.
29. Systemic conditions affecting the etiology, pathogenesis, and
treatment of periodontal disease have the potential for altering the
state of periodontal health and should be identified for adequate
treatment planning.
30. When possible, optimal periodontal health should be estab-
lished before completing the definitive restorative and prosthetic
treatment. After a thorough examination of the patient, a periodon-
tal diagnosis is useful in establishing a logical plan of treatment.
Referral to a periodontist may be helpful.
31. The decision to treat a patient with fixed or removable par-
tial dentures is largely dependent on the number, location, condi-
tion, and supporting structures of the abutment teeth and the size
and contour of the edentulous spaces.
PROGNOSIS
1. A prognosis is an opinion or judgment given in advance of
treatment concerning the prospects for success of therapy and use-
fulness of the restoration or treatment.
2. The prognosis for a restoration and the natural dentition is
positively influenced by oral hygiene and plaque control.
3. The oral cavity should be healthy before placement of defin-
itive restorations.
4. Proper selection of materials and the skillful execution of
treatment enhances treatment success.
5. Tissue tolerance and adaptability of the patient affects the
prognosis of the tissue-borne prosthesis.
6. Compatibility of clinician and patient and the manner of the
clinician during treatment influence treatment success.
7. General health and nutrition may influence the patient’s abil-
ity to use any prosthesis.
8. Psychological factors may pose insurmountable obstacles to
denture wearing.
9. Success in wearing a prosthesis is more likely to be compro-
mised as physical defects become larger.
PRERESTORATIVE TREATMENT
A. Systemic and local
1. Many signs of systemic disorders, such as diabetes, avitamino-
sis, or hormonal imbalances, may manifest themselves by altering
the oral mucosa. This may indicate the need for supportive therapy
before prosthodontic treatment is initiated.
2. Prosthodontic patients with unfavorable tissue response and
senescent individuals, in particular, may benefit from dietary coun-
seling.
3. The success of a removable prosthesis is enhanced by proper
preparation of the remaining oral structures.
4. It is important to recognize the importance of conditioning the
oral mucosa and orofacial musculature for patients requiring re-
movable prostheses.
5. The emotional status of the patient may influence the success
of prosthodontic treatment.
6. Gagging stimulated by dentures may have a psychologic com-
ponent.
B. Patient education
1. Informed patients are usually more receptive and cooperative
than uninformed patients.
2. A program of education, instruction, and discussion about
dental care should continue during the entire treatment period, in-
cluding recall visits.
90
ACADEMY OF DENTURE PROSTHETICS
3. Both oral and printed information help patients understand
and accept treatment goals.
4. Successful dental treatment is enhanced if the patient prac-
tices thorough oral hygiene. It is the dentist’s responsibility to teach
such procedures and the patient’s responsibility to perform them.
5. It is desirable to speak of “prosthodontic treatment” instead of
focusing attention solely on the fabrication of the denture.
6. Patients should be educated as to both the value and the
shortcomings of complete dentures.
7. Patients should be informed that residual ridge resorption oc-
curs in varying, unpredictable degrees and that this will affect the
adaptation and function of their dentures.
8. Treatment with dentures is individual and cannot be stan-
dardized.
9. Patients should be warned of the hazards of “do-it-yourself’
denture-relining kits and their use should be discouraged.
10. A prospective patient should be informed that neuromuscu-
lar adaptation contributes to success in wearing a removable pros-
thesis.
11. For patients who have had radiation therapy to the head or
neck, plaque control instructions and frequent periodic prophylaxis
should be part of care. A thorough oral examination is essential.
Fluorides should be self-administered daily.
12. Patient education and disease control should include the fol-
lowing:
(a) Teaching about diagnosis, etiology, and consequences of
disease
(b) Training in personal plaque control and care of prosthetic
restorations
13. Before completion of treatment, patients should be given the
following information:
(a) The prognosis, both periodontally and prosthetically, is in-
fluenced by diet, systemic factors, and their ability to
maintain a plaque-free environment.
(b) Even with proper professional and personal care, periodon-
tal disease may recur.
(c) When teeth that are retained after periodontal therapy
have a doubtful prognosis, the longevity of the restoration
could be compromised. When possible, such teeth should be
extracted before or during periodontal therapy.
TREATMENT OF ORAL STRUCTURES
1. Each treatment procedure should be directed toward preser-
vation of the oral tissues and normal functions to the extent possi-
ble.
2. Pathosis of hard and soft oral tissues should be corrected when
possible before missing structures are replaced with a prosthesis.
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 satisfactory
functional relationships
3. Traumatic occlusion should be appropriately treated. Treat-
ment may include interocclusal splints, occlusal restorations, selec-
tive occlusal adjustments, surgery, orthodontics, muscle exercise, or
other corrective methods.
4. Before an impression is made for a removable prosthesis, a
program of tissue conditioning should be considered when soft tis-
sue is inflamed, irritated, or distorted.
5. If the examination shows the presence of periodontal disease,
a periodontal consultation should usually follow.
6. Periodontal pathosis should be treated and periodontal health
stabilized before the final preparation of abutment teeth.
JANUARY 1989 VOLUME 61 NUMBER 1
PRINCIPLES, CONCEPTS, AND PRACTICES IN PROSTAODONTICS
7. When a patient is referred to a periodontist, the prosthodontic
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 appropriate
(d) Posttreatment evaluation of periodontal health and rein-
forcement of daily oral hygiene and plaque control care
when needed
(e) Recontouring supporting bone
(f) Reorganizing or augmentation of unattached gingiva
(g) Extraction (before periodontal therapy) of teeth that lack
proper supporting structures, crown form, or position and
would compromise the prognosis of a prosthesis
9. Treatment options when the periodontal condition is more se-
verely involved may include the following:
(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, particu-
larly around teeth to be prepared for a prosthodontic treat-
ment
(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
TREATMENT PLAN
1. After prerestorative treatment is completed, the treatment
plan should be reevaluated and modified as indicated by the patient
response to the following:
(a) Education
(b) Efforts to eradicate or control disease
(c) Exploratory and trial procedures
2. Upon completion of active periodontal therapy, supportive
care, including regular reevaluations of the periodontal status, rein-
forcement of personal oral hygiene, and removal of any etiologic
factors is critical to the long-range maintenance of periodontal pa-
tient health.
PROSTHETIC TREATMENT
I. Basic to most areas of prosthodontics
A. Design, fabrication, and classification
1. The selection and final arrangement of artificial teeth are the
responsibility of the dentist in consultation with the patient.
2. Artificial teeth should be arranged for minimal inhibition of
the tongue and so that the shape of the palatal vault will not be sub-
stantially altered.
3. The external form of a prosthesis should be compatible with
the function of the oral musculature and their overlying tissue.
4. Patient experience with an existing prosthesis should be eval-
uated carefully before extensive preprosthetic surgery is considered.
5. The relationship of the tuberosities relative to the retromolar
pads is best visualized with diagnostic casts articulated in centric
relation at an acceptable vertical dimension of occlusion.
6. There should be accommodation for the coronoid process dur-
ing the 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 pos-
sible, the retainer should be designed to direct forces along the long
axis of the tooth.
THE JOURNAL OF PROSTHETIC DENTISTRY
8. The prosthodontist should know and understand the physical
and chemical properties of all of the materials used in the practice
of prosthodontics.
9. Dimensional changes occur in resin materials during process-
ing procedures.
10. Dimensional changes in dentures can occur from differences
in coefficients of thermal expansion of gypsum products, resins, and
metal flasks. Dentures should be processed with techniques that
minimize these changes.
11. Four areas of concern in the fabrication of any new prosthesis
are comfort, function, esthetics, and phonetics.
12. The design and fabrication of all restorations, both provi-
sional and definitive, should be compatible with maintaining the
health of the periodontium. Areas of concern include margin place-
ment, marginal adaptation, contour of the restoration, and occlusal
relationships. The prosthodontic design should consider crown-root
ratio, length of the edentulous space, root configuration, size, and
contour of the anterior edentulous ridge, occlusal-gingival dimen-
sion, size and configuration of the clinical crown, occlusal scheme
present, and materials to be used.
B. Tooth preparation and soft tissue management
1. The mucosa in edentulous regions may assume an altered sur-
face form and texture as a result of 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 to provide the desired interarch
distance, a more stable denture base, or to permit proper orientation
OF of the occlusal plane.
5. Irritated, inflamed, or distorted mucosa should be treated so
that it is in a state of maximum health before final impressions are
made.
6. Tissue conditioning is more effective when the occlusion is
corrected, the proper vertical dimension of occlusion is restored, the
denture borders are properly extended, and the conditioner is prop-
erly placed and changed as required.
7. Tissue conditioning materials placed on the tissue surface of a
surgical prosthesis can help to compensate for tissue alterations re-
sulting from surgery.
8. Before dentures are placed, areas on the tissue surface of the
denture that transmit 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 ac-
cept dentures.
10. Patients should be informed that meticulous plaque control
is essential to the success of prosthodontic restorations and should
be instructed in the proper maintenance of oral health.
11. When oral surgery procedures are indicated to reduce tuber-
osities, tori, or other hard or soft tissue interferences, the diagnostic
cast or a duplicate of it may be recontoured to the desired shape
and/or a clear plastic template constructed to aid the surgeon in
achieving the desired residual ridge contour.
12. Augmentation and/or revision should be considered for a re-
sidual ridge presenting unfavorable gingival contours for pontic
placement.
C. Impressions
1. A correctly designed and contoured custom impression tray
will facilitate making impressions for the fabrication of fixed or re-
movable partial dentures, complete dentures, and implant prosthe-
ses when certain types of impression materials are used.
2. Impression trays for final impressions should remain dimen-
sionally stable throughout the impression- and cast-making proce-
dure.
91
 3. Preliminary impressions made with modeling plastic impres-
sion compound may he altered hy trimming and/or adding material
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. The borders of the final impression should represent the
extension and contours to be produced in the processed denture.
6. Maximum extension of denture bases within physiologic lim-
its is helpful to distribute forces to the supporting structures, aug-
ment retention and stability, and minimize accumulation of food
particles under the bases.
7. Displacement of soft tissues during the making of an impres-
sion may be partially controlled through the placement of relief in
the tray, by escape holes in the tray, and/or control of the viscosity
of the impression materials.
8. When plaster of paris, zinc oxide-eugenol paste, or similar ma-
terials are used for final impressions for the fabrication of complete
or removable partial dentures, sufficient space between the impres-
sion tray and the mucosa should be present.
9. When gagging is a problem while impressions are being made,
placing the patient in an upright or forward position and/or the ju-
dicious application of 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. Manufacturer’s instructions for each impression material
should be carefully followed for optimum results.
11. The making of 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. All materials used in prosthcdontics should be carefully
selected. The materials should meet ADA specifications where pos-
sible and should be used in accord with manufacturers’ instructions.
2. Impression materials, gypsum products, and other die materi-
als should be mutually compatible to produce accurate dies and
C&S.
3. Cast formation should be accomplished immediately after the
impression-making procedure or within the time recommended by
the manufacturer of each material.
4. The manufacturers’ recommendations regarding the powder-
to-water ratio should be followed when cast materials are mixed.
5. Impressions should not be inverted on the same mix of stone
when casts are formed, that is, either a two-pour or a boxing tech-
nique should be used.
6. The cast produced from an impression should accurately
record all of the details captured in the impression, including the
border contours.
7. Ordinary plaster of paris is not a suitable material for the con-
struction of master casts.
8. When it is mandatory that a cast made of gypsum materials be
hydrated, the cast should be soaked in slurry water instead of tap
water to avoid disintegration of the cast’s surface.
9. Diagnostic casts are helpful for diagnosis, treatment planning,
patient education, and as a permanent record of the status of the
dentition.
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 fabrication of final restorations.
14. Mounting of any cast in an articulator should be accomplished
92
using procedures and materials that minimize dimensional changes
between the mounted cast and the member of the articulator.
15. Vacuum mixing and correct water-to-powder ratios are es-
sential in mixing the final cast materials.
16. Casts should be properly trimmed according to their intended
use.
17. The accuracy of casts made from impressions may be checked
with an occlusal index made in the mouth.
E. Maxillomandibular records and registratiorw
1. Temporomandibular joints are capable of three-dimensional
movementa.
2. A record of the maxillomandibular relationship when the
mandible is in centric relation is a necessary component of compre-
hensive diagnosis.
3. When posterior teeth are missing and mastication has occurred
only on the anterior teeth, an eccentric functional relation of the
mandible to the maxilla may have occurred and 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. The proper conditioning or
positioning of the condyles should be accomplished, where possible,
through prosthodontic services.
5. As used in dentistry, the term vertical dimension refers to the
length of the patient’s facial profile as it may be established by rais-
ing and lowering the mandible in relation to the maxillae (opening
or closing the jaws).
6. The term rest vertical dimension refers to the length of the pa-
tient’s facial profile when the mandible is in its rest position in re-
lation to the maxillae.
7. Mandibular rest position is a postural position and is subject
to the same physiologic and pathologic factors as posture elsewhere
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 dimen-
sion 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 sit-
ting erect in a chair without a headrest or back support or when
standing erect.
11. In the absence of occlusal interference or pathosis, the man-
dible 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 r!nay aid in registering
vertical jaw relationships.
14. It can be difficult to properly assess the correct vertical
dimension of occlusion before the arrangement of the teeth on the
denture base.
15. The alteration of the vertical dimension of occlusion requires
critical judgment. The use of interim diagnostic restorations at the
altered vertical dimension may be indicated.
16. Tissue changes that 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 verti-
cal dimension of occlusion may be lost.
18. Recording maxillomandibular relations is best accomplished
when the patient is relaxed.
19. Centric relation serves as a reference for analysis of an exist-
ing occlusion and for the type of occlusion to be established during
treatment.
20. Centric relation is individual to each patient.
21. On an articulator, centric relation at one vertical dimension
of occlusion may not be the same as at another occlusal vertical di-
mension unless a transverse horizontal axis determination has been
made.
JANUARY 1989 VOLUME 61 NUMBER I
PRINCIPLES, CONCEPTS, AND PRACTICES IN PROSTHODONTICS
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. Because recording of maxillomandibular relations is best ac-
complished when the mandible is relaxed, patients should be trained
to relax the muscles controlling the mandible before centric relation
records are made.
24. Head position influences the recording of centric relation.
25. Centric relation records should be made with minimum clos-
ing pressure.
26. Centric relation records should be repeatable.
27. Eccentric jaw relation records are made to adjust the guiding
elements of an articulator.
28. The recording of centric relation for a removable prosthesis
requires rigid and accurately fitted bases that resist warpage during
clinical use.
29. Properly adapted record bases should be stable on the casts
and incorporate an accurate index on the occlusion rim into which
they may be related for mounting casts on an articulator.
30. 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.
31. Shellac-type record bases are susceptible to deformation.
32. Thick record bases may interfere with the accurate recording
of jaw relations.
33. Occlusion rims should be made of a material that is easily
softened and molded to the desired form, is easily attached to the
record base, becomes sufficiently rigid when cooled to serve as a
temporary occlusal surface, and permits resoftening in selected ar-
eas.
34. The labial, buccal, and lingual contours of occlusion rims may
influence the results when jaw relation records are made. This con-
sideration is especially important when phonetic determinations are
used.
35. The recording of jaw relations may be more accurately
accomplished when the design of the occlusion rims conforms to the
positions and dimensions originally occupied by the natural teeth
and their investing tissues.
36. If an average-value facebow is used, interocclusal centric re-
lation records should be kept to a minimum thickness.
37. Such factors as the nature and extent of prosthodontic ther-
apy and the health of the stomatognathic system, instead of statis-
tical averages, determine the need for recording condylar movement
to set condylar guidance.
38. A remount procedure on a suitable articulator with new max-
illomandibular records is an effective method of identifying occlusal
discrepancies before placement of a prosthesis.
F. Occlusion
1. Because occlusal relationships are not static, the neuromuscu-
lar reflexes may change in response to changes in the occlusal posi-
tion.
2. The occlusion of all prosthodontically treated patients should
receive scheduled reevaluation.
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 equal-
ized contact in centric relation with no interference in eccentric ex-
cursion.
5. The factors of articulation directly under the control of the
dentist during complete denture fabrication are: anterior guidance,
plane of occlusion, cusp height, and compensating curve.
6. Occlusion and articulation of artificial teeth should be physi-
ologically compatible with the remaining natural teeth and other
parts of the masticatory system.
7. In centric occlusion, all posterior teeth should contact simul-
taneously.
THE JOURNAL OF PROSTHETIC DENTISTRY
8. Orthodontic procedures may play an important role in the
correction of some occlusal disharmonies.
9. The occlusion should be analyzed and necessary occlusal alter-
ations accomplished before final impressions are made and a pros-
thesis is fabricated.
10. Attempts to create artificial occlusal surfaces in the partially
edentulous patient should be preceded by the elimination of occlusal
discrepancies in the natural teeth.
11. A thorough examination of the occlusion of the remaining
natural teeth should include properly mounted diagnostic casts.
12. Contact of the teeth during speech may indicate insufficient
interocclusal distance.
13. Physiologic stimulation of teeth and ridge structures is advis-
able. Excessive forces or dysfunction can be harmful and destruc-
tive.
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, sat-
isfactory speech, and good appearance.
16. Extreme caution should be exercised when performing proce-
dures that will change the vertical dimension of occlusion. If the ex-
isting vertical dimension of occlusion is to be altered, a trial period
at the new position is recommended to ascertain that a physiolog-
ically 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 pro-
cessing.
20. Abnormal swallowing closures do not necessarily terminate at
centric relation.
21. Provision of food escapeways in artificial posterior teeth adds
to 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: condylar inclination, which is established
by the patient, and 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 be positioned nei-
ther more distal than the anterior border of the retromolsr pad nor
on the distal incline of the residual ridge.
2. When only the anterior teeth in a partially edentulous arch re-
main, the artificial posterior teeth should be arranged on a record
base and tried in the patient’s mouth to verify the jar relations, oc-
clusion, and appearance.
H. Esthetic considerations
1. Natural anterior teeth may become more uniform in color as
their incisal edges become worn. They may not present the same in-
cisal 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 ar-
ranging 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 as-
sessed and discussed with the patient before treatment is started.
7. Preextraction records, which become part of the patient’s
93

record before any remaining natural teeth are removed, may be
helpful during future treatment.
8. A preextraction protile record of the face is best made while the
teeth are in maximum contact.
9. The dentist is responsible for esthetics. His work authorization
to the technician should give specific instructions regarding esthetic
factors.
10. Tooth color selection should be communicated to the dental
technician through appropriate terminology.
11. Dental treatment rooms and the dental laboratory need sim-
ilar light conditions for optimum shade matching.
12. The esthetic features of the restorations should be observed
in artificial and natural light.
13. Shade selection should be under conditions that simulate
natural daylight.
14. Resin denture base materials should optimally reproduce the
color and characteristics of the patient’s oral tissues that are being
replaced.
15. The incisal length of maxillary anterior teeth should be
determined esthetically and phonetically by arranging the teeth on
the record base.
16. The natural appearance of replacement teeth may be en-
hanced if various tooth colors and molds are used in an artistic ar-
rangement of the anterior teeth.
17. Reflective surface and texture are critical to attaining a shade
match.
18. Modification of standard artificial teeth may improve the ap-
pearance of a removable prosthesis, especially for mature patients.
19. The dentist needs a working knowledge of the science of color
to match the colors of natural teeth.
20. Esthetic requirements of a patient should be met with due
consideration for the periodontal health of the tissues and proper
function. Rigid esthetic requirements that conflict with functional
requirements may preclude treatment.
I. Initial placement of restorations (insertion)
1. Adequate time should be allowed for the appointment involv-
ing initial placement of restorations so that the patient fully com-
prehends the importance of his or her responsibilities in the success
of the restorations.
2. The tissue surface of each denture base 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 interfering re-
gions 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 and a future informational refer-
ence.
5. The patient should be recalled for necessary adjustments at an
appropriate interval after the initial placement of a removable
prosthesis.
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 that does not
end with the placement of the oral or facial prosthesis.
2. The patient should be impressed with the need for routine ex-
aminations to evaluate the occlusion and assessthe response of the
oral environment to the prosthetic restoration.
3. Proper diet should be emphasized to all prosthodontic pa-
tients.
4. The patient’s name, date, articulator number, condylar set-
tings, and other pertinent data should be indelibly recorded on ar-
ticulated diagnostic casts, treatment casts, and dies, which should
94
ACADEMY OF DENTURE PROSTHETICS
be retained by the dentist. The records are a valuable aid in further
treatment and for medicolegal reasons.
5. Care after placement should include regular supportive (main-
tenance) periodontal care and care of the prosthetic restorations.
K. Interim and immediate restorations
1. After surgery and appropriate healing, the original prosthesis
may require revision or replacement.
2. Some temporomandibular joint symptoms may be alleviated
by properly constructed interim restorations.
3. Placing tissue-conditioning materials on the tissue surface of
a surgical prosthesis is an acceptable method of compensating for
tissue changes after surgery.
4. A transitional removable partial denture may be considered as
a temporary treatment modality before immediate complete den-
tures to help the patient adapt to wearing a prosthesis.
5. Immediate restorations generally are considered provisional,
to be followed later by definitive treatment.
II. Fixed partial dentures
A. Diagnostic procedures
1. For most fixed partial dentures, the patient’s diagnostic casts
should be mounted in a semiadjustable or fully adjustable articula-
tor capable of accepting eccentric excursive and centric relation
records.
2. The maxillary cast should be mounted in the articulator with
the aid of a facebow.
3. Pantographic tracings may provide additional diagnostic in-
formation concerning the patient’s jaw movements.
4. Casts mounted in an articulator should be evaluated:
(a) To determine anteroposterior and lateral excursive inter-
ferences
(b) To select the appropriate path of placement
(c) To decide whether to alter the vertical dimension of occlu-
sion 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 es-
thetic result
(b) To indicate the amount of tooth reduction required
(c) To aid in fabrication of provisional restorations
(d) To provide a visual aid during treatment-planning discus-
sions 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 using
the mounted diagnostic casts.
B. Tooth preparation
1. Preparation of a tooth should be planned and executed so that
adequate retention and resistance form are developed.
2. The addition of boxes, grooves, or pinholes to a preparation
may provide increased resistance to dislodgment of a cast metal
restoration.
3. Sufficient tooth structure must be removed to preserve the in-
tegrity of the restoration, provide the desired esthetic result, and
allow the restoration to be fabricated without being overcontoured.
The amount of tooth reduction needed will vary depending on the
restorative material being used.
(a) Occlusal reduction for a cast metal restoration should be a
minimum 1 to 1.5 mm for the lingual cusps of the maxillary
teeth and buccal cusps of the mandibular teeth.
(b) Preparation of the occlusal surfaces should replicate as
JANUARY 1989 VOLUME 61 NUMBER 1
PRINCIPLES, CONCEPTS, AND PRACTICES IN PROSTHODONTICS
nearly as possible the anatomy of the cusps and grooves to
avoid over or under reduction of the tooth.
(c) Adequate peripheral reduction, especially near the margins,
increases the 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 the margins of cast restorations
may be desirable if the requirements for retention and 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
some situations, it may be necessary to locate the finish line
on cementurn, 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 pul-
pal trauma. The use of an air and water coolant is recommended
during tooth reduction with rotary instruments.
6. Endodonticahy treated teeth may require the use of a core
buildup or a dowel and core to obtain the desired retention and re-
sistance form.
7. Periodontal health should be established before or in concert
with the restorative treatment. Preservation of the supporting
structures should be a primary consideration in the design and fab-
rication of fixed partial dentures. Teeth should be prepared in re-
lation to healthy tissue. The gingival terminus should not violate the
epithelial attachment.
C. Impression making
1. An impression material should be selected because its physical,
chemical, and working properties are best suited for the clinical
problem being treated.
2. Impression materials used should meet the specifications of the
ADA Council on Dental Materials, Instruments, and Equipment.
3. The use of a full-arch custom tray may facilitate making im-
pressions when elastomeric impression materials are used.
4. Gingival displacement may be accomplished by using mechan-
ical, 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 gingival
retraction is employed.
(c) Epinephrine-impregnated cords should not be used on pa-
tients with certain types of cardiovascular disease, hyper-
thyroidism, or a history of epinephrine hypersensitivity.
(d) Electrosurgical gingival preparation should not be used on
patients with cardiac pacemakers.
5. Careful management of the interface between tooth and peri-
odontium is integral to the preservation of periodontal health. Ide-
ally, an impression should not extend subgingivally; however,
certain clinical situations may necessitate subgingival margin place-
ment. Invasive techniques to displace gingival tissue should be min-
imally traumatic.
D. Interocclusal records
1. The time lapse between securing an interocclusal record and its
THE JOURNAL OF PROSTHETIC DENTISTRY
use in mounting caste in an articulator should be consistent with
minimizing inaccuracies inherent in the recording material being
used.
2. A separate appointment for making interocclusal records after
the working casts have been recovered from the impressions will
permit verification of the records while the patient is present.
3. Numerous materials and techniques will enable accurate
reproduction of interocclusal relationships. Personal preference and
clinical circumstances will dictate which methods are used.
4. Interocclusal records trimmed so that only cusp-tip indenta-
tions remain facilitate accurate positioning of the caste in the record
before their mounting in an articulator.
5. When limited numbers of teeth are being restored, the interoc-
clusal registration may be made with the remaining unprepared
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 registration 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 and assists in positioning the
condyles in their appropriate positions.
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; that relationship is then captured with
the recording medium.
9. At least two registrations should be used to verify the accuracy
of the centric relation mounting of the mandibular cast in the artic-
ulator.
10. When a significant edentulous segment exists, an interoc-
clusal record to relate the casts for a fixed partial denture should be
made by using 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
responsibility of the dentist.
E. Provisional restorations
1. Provisional restorations should incorporate the same qualities
as the final restoration, including marginal integrity, esthetics, form,
and function, while maintaining the health of the abutment teeth
and supporting structures.
2. Many acceptable materials are available for fabricating provi-
sional restorations. The position of the tooth in the arch, the type
of tooth preparation, the expected length of service, and whether it
is a single unit or a fixed partial denture will influence the choice of
material.
F. Occlusal considerations
1. A cusp-marginal ridge occluaal relationship is found in most
adult natural occlusions. This type of occlusal morphology may be
used in the fabrication of 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 occlusion
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
of developing a group-function occlusion in cast restorations.
5. A mutually protected occlusion may be indicated when there
are periodontally healthy anterior teeth, an Angle class I jaw rela-
tionship, and the posterior teeth are not in a reverse occlusion in
which 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 in-
95
tercuspation is coincident with centric relation and the occlusal
forces are directed along the long axis of the posterior teeth. The
anterior teeth protect the posterior teeth in eccentric movements
and the posterior teeth protect the anterior teeth in the intercuspal
position.
7. Lateral excursive contacts on the balancing side are considered
undesirable in either a group-function or mutually protected occlu-
sion.
8. Care must be exercised in the fabrication of anterior restora-
tions so that the vertical and horizontal overlap and the configura-
tion of the lingual surfaces of tb.e maxillary restorations are in har-
mony 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 of several weeks to
several months during which the patient is allowed to function at the
desired vertical dimension of occlusion before the definitive resto-
rations are fabricated.
G. Casting try-in and verification
1. After removal of the provisional restorations, the prepared
teeth should be examined carefully to assure that 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 examine the internal
surfaces of cast restorations to make sure that they are free of small
bubbles, investment, or deposits of veneering material before place-
ment on the prepared tooth is attempted.
3. A disclosing medium may be used on the internal surface of a
casting to locate discrepancies that prevent the restoration from
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 designed to contact the residual ridge should do so in
a passive manner.
6. The apical form of the pontic should be designed and adjusted
to allow the patient to adequately perform oral hygiene procedures.
7. Equilibration of occlusion discrepancies of definitive restora-
tions should be carried out by using relatively smooth rotary instru-
ments and a thin marking medium.
8. Articulating strips of different colors can be used as an aid to
help differentiate between centric and lateral excursive interfer-
ences during equilibration of the definitive restorations.
9. The use of a remount procedure may facilitate occlusal equil-
ibration of the definitive restorations when numerous teeth are be-
ing restored.
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 resto-
rations, the dentist should perform final surface characterization,
contouring, and shade modification with the patient present.
12. Fixed partial dentures replacing anterior teeth should provide
lip support and satisfy the patient’s esthetic, phonetic, and func-
tional requirements.
13. The trial fitting procedure should include procedures that
verify complete seating of the castings and marginal integrity and
that verify proper embrasure 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. Before cementation, the metal should be repolished and the
porcelain polished or reglazed in areas where adjustments have been
made.
2. Trial placement of the restoration with a temporary cement
may be indicated to assesstissue and patient response.
3. The cement selected should meet the specifications of the
96
American Dental Association Council on Dental Materials, Instru-
ments, and Equipment.
4. Different types of cements are available for final placement of
a restoration. The dentist should select the cement with physical,
chemical, and working properties best suited to each clinical situa-
tion.
5. The tooth should be cleansed, isolated, and dried; where indi-
cated, a cavity varnish should be applied before final cementation.
6. The manufacturer’s instructions for manipulating the cement
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 that none remains to act as a gingival irritant.
9. The occlusion should be reexamined after cementation and
equilibrated, if necessary.
10. Patients should be thoroughly instructed regarding oral hy-
giene procedures, aids, and devices to facilitate interproximal and
pontic tissue surface cleansing.
11. The patient should be given an appointment for follow-up
care after placement of the restoration.
I. Periodic recall examination
1. Periodic recall after placement should be an essential part of
fixed prosthodontic therapy. Early detection of potential problems
through recall examination after placement may prevent failure of
the restorations.
III. Removable partial dentures
A. Refining diagnostic procedures and preparatory treatment
1. The 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 orthodon-
tics to restore proper harmony between the musculature, the tem-
poromandibular joints, and the occlusion of the teeth.
2. The patient’s periodontal health is an important consideration
in treating a patient with a removable partial denture.
3. 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.
4. Diagnostic casts are necessary in evaluating the degree of
mouth preparation and tooth modification required for removable
partial denture framework design.
5. Planned mouth preparation and tooth modification may be
done on the diagnostic cast before actual patient preparation and
can serve as a guide for subsequent intraoral procedures.
6. A dental surveyor must be used to locate undercuts and guide
surfaces in relation to the planned path of placement on the diag-
nostic cast.
7. 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 dislodg-
ment. Properly prepared guiding surfaces contribute to the reten-
tion and stability of the removable partial denture.
8. 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, vestibular
depth, frenum movement).
B. Design, fabrication, and classification
1. The treatment planning, mouth preparation, and designing of
removable partial dentures are professional responsibilities to be
accomplished by the dentist before master casts are presented to a
dental laboratory to accomplish various steps in the fabrication of
the prosthesis.
JANUARY 1989 VOLUME 61 NUMBER 1
PRINCIPLRS, CONCEPTS, AND PRACTICES IN PROSTAODONTICS
2. The classification of a partially edentulous arch should permit
immediate visualization of the type of arch being considered. It
should also permit immediate differentiation between the tooth-
borne and the tooth- and tissue-supported removable partial den-
ture.
3. Philosophies of removable partial denture support are based
on principles of broad or selective distribution of occlusal forces.
4. The basic purposes of the component parts of removable par-
tial dentures are: to provide support by means of rests on abutment
teeth and by denture bases on edentulous ridge areas; to provide
primary retention by direct retainers; and to provide selective force
transmission through placement of rigid components of the remov-
able partial denture.
5. A removable partial denture should restore arch integrity,
thereby preventing further change of both maxillary and mandib-
ular arches.
6. An important consideration in removable partial denture de-
sign is to maintain and improve the health of the remaining teeth
and supporting structures. Impingement of any part of the prosthe-
sis on gingival tissues should be avoided.
7. When a removable partial denture is supported by both natu-
ral teeth and the residual ridge(s), the design should use both sup-
porting 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 pa-
tient management, particularly for the first months after 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 denture
should minimize the retention or impaction of food.
12. A survey of both the diagnostic and the master casts is essen-
tial for removable partial denture fabrication.
13. One method of stress distribution to abutment teeth is to use
multiple abutments.
14. An isolated premolar adjacent to a distal extension base may
not be an adequate primary abutment for a removable partial den-
ture. The prognosis can be improved by splinting with a fixed par-
tial denture.
15. Forces that produce torque on abutment teeth and the alve-
olar residual ridge should be controlled and minimized in the design
of direct retainers for distal extension removable partial dentures.
16. A removable partial denture with distal extension bases may
use stress directors to minimize stress distribution on abutment
teeth.
17. Major connectors should be designed to have sufficient rigid-
ity 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 supporting
structures, design of the prosthesis, and the accuracy of fit of the
framework and the bases.
19. A removable partial denture base that derives part of its sup-
port from the residual ridge should not displace the underlying mu-
cosa except during masticatory function.
20. In tooth- and tissue-supported removable partial dentures,
denture bases should provide optimum support during occlusal
loading.
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 rela-
tionship of the vertical spindle of the surveyor to the cast indicates
the most desirable path for placement and removal of the completed
restoration.
THE JOURNAL OF PROSTHETIC DENTISTRY
23. Abutment teeth should be prepared by modifying unfavor-
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, and stabi-
lizing and retentive areas.
25. Fixed restorations that are to be integrated with removable
prostheses should be surveyed in the wax pattern stage and verified
after casting, after veneering, and before cementing.
26. Indirect retainers establish a positional reference point for the
removable partial denture and provide better stress distribution by
transferring forces to structures other than the abutment 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 combi-
nation 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
that unfavorable forces on abutments will be minimized.
30. Each direct retainer (clasp) requires reciprocation to reduce
movement of the abutment tooth during placement and dislodg-
ment 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. A direct retainer (clasp) design that will minimize the display
of metal should be chosen when appearance is a consideration.
33. The undercut gauge indicates the amount of infrabulge at the
site selected and the distance the retentive clasp arm must flex or
deform to pass over the greatest contour of the tooth.
34. Direct retainers (clasps) should not 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
the existing natural teeth.
36. Occlusal and incisal rests are important supporting elements
of removable partial dentures and, thereby, help to resist horizontal
and vertical forces applied to the prostheses. Other components that
contact teeth above the survey line may also provide stability.
37. The major connector should be located so that gingival
impingement will be avoided and its contact will be compatible with
structures that move during function.
38. Direct measurements of the distance between the active floor
of the mouth and the lingual gingival tissues are essential to selec-
tion and placement of mandibular major connectors.
39. Major connectors join the denture base(s) to other parts of
removable partial denture and help distribute functional forces.
40. The angle formed by the occlusal rest and the vertical minor
connector should be slightly less than 90 degrees.
41. The use of permanent soft denture base material for defini-
tive removable partial denture fabrication is not recommended.
42. Mandibular labial bar major connectors may be used when
lingual inclinations of remaining teeth contraindicate the use of a
conventional lingual major connector.
43. A hinged continuous labial bar may be indicated in patients
with missing key abutments, unfavorable tooth contours, unfavor-
able soft tissue contours, and teeth with questionable prognosis.
44. The use of porcelain teeth should be limited to instances in
which the opposing occlusal surfaces will not be subject to acceler-
ated functional wear.
45. Acrylic resin teeth should be considered for use in removable
partial dentures when there is aberrant spacing in the edentulous
area.
46. The flexibility of a clasp varies with its length, thickness,
width, curvature, taper, form in cross section, metallurgical compo-
sition, and handling during fabrication.
97

47. It is the dental technician’s responsibility to follow the den-
tist’s work authorization or design and to fabricate the removable
partial denture framework so that it accurately fits the undamaged
master cast. If these criteria are met and the framework does not fit
the mouth, the fault lies with errors occurring before technical fab-
rication.
48. The metal framework of a removable partial denture 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: the abut-
ment tooth may be recontoured or shortened and the denture base
readapted with autopolymerizing or visible light-curved resin; a
coping can be placed at a later date and the denture base readapt-
ed; there are fewer problems in making an altered cast impression
or relining the denture base; and the denture base can be adapted
to the abutment tooth under some degree of occlusal loading of the
artificial teeth.
C. Tooth preparation and soft tissue management
1. The occlusal rest should be spoon-shaped and deeper in ite
central portion. Surface angles of the preparation should be rounded
and the preparation 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 so that the resultant force is
directed parallel to the long axis of the tooth. When recontouring
is not feasible, a restoration that incorporates a rest seat may be
required.
4. Rest seats must be strong enough to endure functional stress,
preferably be prepared in enamel or a metallic restoration, provide
a vertical contact for the metal framework, be rounded, and conform
to the existing coronal anatomy. The rest seat preparation should be
sufficiently deep to prevent rest fractures. The opposing dentition
may require modification to provide space for adequate rest thick-
ness.
5. If possible, rests should not be located on habitual occlusal
contacts.
6. Cingulum rest seats may be prepared in teeth having a natu-
rally 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
extending 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 pro-
vide 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-
ated to aid in retention and stability of the removable partial den-
ture.
12. Guiding surfaces should be aligned to the, path of insertion,
curved buccolingually to follow tooth form, straight occlusogingi-
vally, and dispersed in the arch as much as possible.
13. Guiding planes should be completed on the unrestored abut-
ment teeth before crowns or other teeth are constructed. Thus, they
serve as a guide for crown contours.
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ACADEMY OF DENTURE PROSTHETICS
14. Line angles of crowded anterior teeth that will receive a lin-
gual plate or continuous clasp, proximal line angles of tipped or ro-
tated teeth, and buccal and lingual surfaces of tipped teeth may be
recontoured to permit better framework placement.
15. The fixed splinting of teeth to be used as abutments for
removable 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 that
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 that have been modified must be
highly polished and should receive fluoride treatment.
19. Soft tissues that have been distorted and displaced by a pre-
vious removable partial denture should be returned to normal health
and contour before impressions are made for a new removable par-
tial denture.
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 composite
resins or metal castings bonded to acid-etched enamel.
D. Final impressions
1. When properly used, reversible and irreversible hydrocolloids
and elastomeric impression materials may be acceptable for remov-
able partial denture impressions.
2. One concept of impression making uses a secondary impression
(altered cast removable partial denture impression) to record the
supporting tissues of the denture base. Mandibular distal extension
removable partial dentures usually require a secondary impression
technique or relining procedure to improve the stability and support
of the prostheses.
3. One potential complication of the altered cast impression pro-
cedure is incorrect or incomplete seating of the framework in the
mouth or on the cast.
4.’ Final impressions should be carefully inspected to verify that
all critical soft and hard tissue areas are accurately recorded, that
voids are not present in rest seats, and that the impression material
has 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 after
removal from the mouth.
7. Most final impressions should be cleaned of saliva and other
debris, disinfected, and poured in improved stone immediately af-
ter 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 retro-
molar pad.
9. A posterior palatal seal on a removable partial denture with full
palatal coverage may prevent the ingress of food and aid in reten-
tion during forceful expulsion of air through the mouth.
E. Casts
1. The master cast must be an exact replica of the oral structures.
It should be dense, clear of debris, without critical voids, and pos-
sess 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 that is compatible with the material used for making the im-
pression.
4. Duplicate casts are helpful to communicate removable partial
JANUARY 1989 VOLUME 61 NUMBER 1
PRINCIPLES, CONCEPTS, AND PRACTICES IN PROSTHODONTICS
denture design to the technician. Diagnostic casts are not recom-
mended for this purpose if restorative procedures or recontouring
have significantly altered the contours of teeth subsequent to the
making of the 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 occlusion 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 fabrication
should be trimmed so that the base is flat, the walls are vertical, and
the land areas are definite; mandibular casts should have flat,
smooth lingual land areas.
9. Accurate casts that have been neatly trimmed, carefully
designed, 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-sup-
ported removable partial dentures must be physiologically adjusted
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 ad-
justment to achieve their optimal fit. Fitting can best be accom-
plished by using a disclosing medium.
6. Retentive clasp arms of removable partial dentures may not be
passive unless the framework is completely seated.
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 at-
tachment occurs.
G. Maxillomandibular records
1. Before beginning preparation of abutment and related teeth,
an accurate occlusal record used to mount diagnostic casts in an ar-
titular at the proper vertical dimension may be helpful.
2. The recording of maxillomandibular relation records for distal
extension removable partial dentures requires accurately adapted
denture bases attached to the framework;which correctly relates to
the remaining teeth.
3. Interocclusal registrations should be made with the natural
teeth in contact at maximum intercuspation in patients for whom
the existing occlusion is physiologic and the prognosis is good.
4. Interocclusal registrations should be made in centric relation
before a definitive occlusal pattern or arrangement is developed for
patients who show evidence of traumatogenic occlusion.
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.
7. In tooth- and tissue-supported removable partial dentures, the
recording of maxillomandibular relationships is best performed by
using record bases attached to frameworks that are fabricated after
an altered cast impression procedure.
8. The vertical dimension of occlusion established for the remov-
able partial denture must be coincident with the remaining natural
dentition.
H. Occlusion
1. To articulate properly, the occlusion of a removable
THE JOURNAL OF PROSTHETIC DENTISTRY
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. The occlusal surfaces of opposing natural teeth may require
adjustment before removable partial denture service is provided.
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 interfere
with complete closing contact or eccentric movements of the
remaining natural dentition.
6. Dentitions that include removable partial dentures provide
less masticating efficiency than natural dentitions with similar con-
tact areas.
7. Processed removable partial dentures may be returned to the
articulator before removal from the master cast to adjust for
processing changes. This procedure reestablishes and verifies the
intended vertical dimension of occlusion.
8. Distal extension removable partial dentures may be remounted
in the articulator to refine centric and eccentric occlusal contacts.
This adjustment should follow base modification by using 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. The accuracy of the articulator mounting should be verified at
the try-in appointment.
3. The appearance of the removable partial denture should be
satisfactory to both patient and dentist.
4. Anterior artifical teeth should be tried in the mouth to verify
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.
a relative or friend of the patient present at the try-in appointment.
6. Waxing for proper esthetic form and for physiologic function
should be accomplished before processing of the denture base ma-
terial.
7. The artificial teeth should be positioned for optimal centric
relation and eccentric contacts.
8. The centric relation should be verified after the accuracy of the
vertical dimension of occlusion has been determined.
J. Esthetic considerations
1. The effect on appearance should be considered in designing
direct retainers for removable partial dentures.
2. Artificial teeth adjacent to abutment teeth may be contoured
to accommodate retainers.
3. In the partially edentulous patient with a well-formed an-
terior residual alveolar ridge, anterior teeth that are adapted to the
ridge with no labial denture base may provide optimum appear-
ance.
K. Initial denture placement
1. Denture base border extension and thickness should be veri-
fied during placement.
2. The denture bases and major connector should be checked with
disclosing medium to justify areas of undesirable pressure.
3. The occlusion may require adjustment to provide planned
partial contacts in maximum intercuspation and lateral excursions.
99
 4. Verbal or written home care instructions with demonstrations
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 contoured 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 denture placement
1. The proper maintenance of the prosthesis and the supporting
structures is a major factor in the success of a removable partial
denture.
2. Most patients who have removable partial dentures should be
reexamined at least semiannually and more frequently, if indicated.
3. Written instructions aid in educating patients effectively.
4. Properly designed brushes and appropriate instructions should
be provided to patients to facilitate cleansing of removable partial
dentures and supporting teeth.
5. Application of fluoride to the natural teeth by using the pros-
thesis or on individual applicator as a carrier may be indicated.
6. Instructions for cleansing and stimulation around abutment
teeth and the remaining natural teeth are essential.
7. Removable partial dentures usually should be removed from
the mouth when the patient goes to bed.
8. Distal extension removable partial dentures should be exam-
ined periodically to evaluate ridge resorption, stability, occlusion,
and framework displacement. Variations from optimum should be
corrected.
M. Interim restorations
1. Interim removabie partial dentures may facilitate residual
ridge remodeling and help maintain the vertical dimension of
occlusion after removal of posterior teeth.
2. Interim removable partial dentures can be used for diagnostic
purposes in determining proper vertical dimension of occlusion, es-
thetic and phonetic requirements, and to assessthe patient’s ability
to cooperate and cope with the wearing of a prosthesis.
IV. Maxillofacial prosthetics
A. Scope of manillofacial prosthesis
1. In a society that values appearance, those who lack eyes, ears,
a nose, facial and mandibular tissues, or who exhibit severe scar tis-
sue and malformed parts of the face, neck, and oral cavity may be-
come less socially acceptable. Although developmental defects
afford ample time for behavioral adjustments to be made, sudden
traumatic and surgical defecta may diminish the patient’s quality of
life. Rehabilitation of the maxillofacial patient into society requires
a broad knowledge of prosthodontics, plus the capacity for compas-
sionate patient management.
B. Refining diagnostic procedures
1. The maxillofacial prosthodontist is an integral member of the
interdisciplinary team that treats individuals with oral, cranial, and
facial defects.
2. The evaluation of a patient’s requirements for maxillofacial
care generally comprises dental, medical, and surgical histories;
psychosocial assessment; speech evaluation; and clinical examina-
tion. Diagnostic aids include articulated maxillary and mandibular
casts and oral radiographs. Maxiliofacial patients may require
radiographs of related facial structures.
3. When possible, all prospective patients for head and neck sur-
gery who are potential candidates for any maxillofacial prosthesis,
should be seen by the maxillofacial prosthodontist for diagnosis and
pretreatment evaluation before surgery, radiation therapy, or che-
motherapy.
100
4. The prosthetic prognosis for patients after irradiation is less
favorable because of changes in supporting structures. Consider-
ation must be given to trismus, fibrosis, xerostomia, hypogeusia, ra-
diation caries, soft tissue fragility, and osteoradionecrosis.
5. Corrective surgery may be indicated to improve function,
comfort, and natural appearance for patients requiring maxillofacial
prostheses.
6. All dental structures that may provide valuable retention, and
support of a maxillofacial prosthesis should be preserved.
7. Facial prostheses are indicated when no further reconstructive
plastic surgery is to be performed or an immediate or provisional
prosthesis is needed after resective surgery.
8. The ideal material for facial prostheses should be biologically
compatible, flexible, translucent, able to retain extrinsic and intrin-
sic color, eazy to clean, lightweight, durable, color stable, inexpen-
sive, easy to fabricate, and finishable to a fine edge.
9. The palatal lift prosthesis is indicated for palatal incompe-
tency and 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 deferred
or contraindicated.
12. An obturator feeding aid may assist in the normal feeding of
a cleft palate infant and can be discontinued when the infant can eat
normally without it.
13. The preparation of a patient for a obturator prosthesis may
require supportive dental treatment, including restorations for the
remaining dentition of both dental arches to achieve proper support
and retention of the prosthesis.
14. After a hemimandibulectomy including the condyle, the pa-
tient should be instructed in exercises or have a mandibular resec-
tion prosthesis with a guide fabricated in an attempt to minimize
deviation of the mandible 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 surgical
procedure for resection of the maxillae.
18. Certain oroantral and oronasal palatal defects require simple
coverage by the prosthesis base; others need obturation by extension
of the prosthesis base to enhance retention, stability, and support
of the completed restoration.
19. A custom conformer prosthesis, which can be sequentially in-
creased in size, may be required to enlarge the contracted socket
before an acceptable artificial eye can be constructed.
20. Maxillofacial prosthesis may be transitional restorations un-
til definitive surgery is performed.
C. Design features and considerations
1. A maxillofacial prosthesis should be designed and fabricated so
that the residual anatomic structures will perform the functions of
speech, respiration, mastication, and deglutition with minimal im-
pediment.
2. Maximum tissue coverage supported by residual bone is desir-
able for maxillofacial prostheses.
3. A surgical obturator prosthesis should be lightweight, strong,
easy to repair and alter, and 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 prosthesis.
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. Resilient, flexible materials that extend into desirable under-
cut areas of nasal or palatal cavities may be used for added reten-
tion of the prosthesis.
IANUARY 1989 VOLUME 61 NUMBER 1
PRINCIPLES, CONCEPTS, AND PRACTICES IN PROSTEODONTICS
7. The use of resilient or adaptive lining materials may be indi-
cated for maintaining prostheses during growth, development, and
postsurgical healing.
8. The pharyngeal part of a speech-aid prosthesis should extend
to the level of maximum muscle activity in the nasopharynx.
Normally, this will be slightly above the anterior tubercle of
the first cervical vertebra or on the palatal plane in the adult pa-
tient.
9. The palatal extension section can be made of a cast metal bar
traversing the soft palate anteroposteriorly and ending in a reten-
tion loop midway in the nasopharyngeal cavity.
10. Speech-aid prostheses should be fabricated in maxillary, pal-
atal, and pharyngeal sections. Each section may require refitting and
use by the patient before succeeding sections are made.
11. A facial prosthesis should be formed so that peripheral bor-
ders are thin, translucent, and blend with facial anatomy to conceal
the edges of the prosthesis.
12. The use of auxiliary aid for retention of maxillofacial pros-
theses such as resilient material into undercuts, spectacle frames,
intermaxillary springs, sectional swivel hinges, magnets, implants,
and adhesives should be considered on an individual basis.
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
facioliigual 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. The degree to which satisfactory appearance can be realized
in maxillofacial restorations may be limited by unfavorable ana-
tomic relationships.
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 fabricated for placement after
orbital resection.
21. A surgical obturator prosthesis improves speech, mastication,
and deglutition; maintains packings of skin grafts in position; and
may improve patient morale.
22. The use of acrylic resin artificial teeth for maxillofacial pros-
theses is usually advisable.
23. Even though the long spans and extended denture bases cov-
ered by removable partial dentures that incorporate maxillofacial
prostheses pose special design problems, the basic principles of
support, stability, and retention remain the same as for conventional
removable partial dentures.
D. Tooth alterations in enamel
1. In maxillofacial prosthetics, judiciously recontouring enamel
to improve esthetics, preparing guide planes, removing interfer-
ences, preparing rest seats, correcting occlusal disharmonies, and
using methods to augment retention are basically the same as for
conventional removable partial dentures.
2. In developmental deformities, tooth positions may be more
aberrant than normal and thus require an overdenture design after
coronal reduction and complete coping coverage have been com-
pleted.
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 than desirable.
4. In situations involving chronic tissue abuse with lack of proper
THE JOURNAL OF PROSTHETIC DENTISTRY
oral hygiene and routine dental care, the dentist should exercise
caution in the use of tissue-conditioner relines, particularly where
they may contact highly sensitive respiratory mucosa.
E. Final impressions
1. Impression procedures for extraoral and intraoral defects are
influenced by the character of the remaining tissues.
2. Impressions for diagnostic caste of maxillofacial prosthetic pa-
tientc 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 contraindicated
for many irradiated patients
4. A complete or sectional facial impression may be indicated for
the fabrication of 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. The impression of the nasopharynx for the fabrication of any
speech-aid prosthesis 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, for
example, dental impression wax, may be needed for an improved
border seal.
F. Master casts
1. Master casts for maxillofacial patients require the same
considerations and qualities as removable partial denture casts.
G. Framework try-in
1. Framework try-in and maxillomandibular recording proce-
dures are similar to those for removable partial dentures.
2. Additional care is required in making jaw relation records on
large mobile record bases to avoid displacement of the record base
during registration.
3. Discontinuity defects of the mandible require special skills,
methods, materials, and patience when jaw relation registrations are
attempted.
4. When there is loss of mandibular continuity, some movements
of 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 is one with a
consistent pattern of duplicable relationships made without tension
or force.
H. Wax 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 max-
illofacial defects.
3. A clay or wax sculpture with a properly aligned artificial eye
should be used for trial fittings of an orbital prosthesis before final
processing.
101

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 and corrected 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 oc-
clusal 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 maxilla
or mandible.
5. It may be necessary to accept an occlusion that is not bilater-
ally balanced in eccentric occluding positions for an edentulous
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 removable
partial dentures, There should be special emphasis on patient edu-
cation.
2. Placement of a surgical obturator prosthesis for maxillary re-
sections 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 adjusted
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 an 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 ma-
terials.
5. Rehabilitation of the maxillofacial patient after surgery may
require speech assessment, psychosocial evaluations, physical ther-
apy, and vocational guidance.
6. Patients with oral neoplasms frequently have a history of
mouth neglect and poor oral hygiene. Preventive dentistry and ed-
ucation in good oral hygiene are necessary components of effective
aftercare.
7. Facial prostheses require periodic replacement because of tis-
sue changes and the unstable properties of available materials.
8. Adhesives used for retention of facial prostheses should be non-
irritating and nontoxic to the skin and mucous membrane, suffi-
ciently flexible to move with surrounding tissues, compatible with
the material of the facial prosthesis and the patient’s skin, strong
enough to retain the prosthesis, easily cleaned from tissue and pros-
thesis, stable, and incapable of supporting bacterial growth.
9. Frequent reevaluation for maxillofacial patients is necessary
because of possible rapid tissue and occlusal changes often associ-
ated with unstable restorative materials frequently used.
10. Surgical obturator prostheses provided for a maxillary resec-
tion must be relined periodically during the healing period to assure
patient comfort and function.
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ACADEMY OF DENTURE PROSTHETICS
V. Complete dentures
A. Refining diagnostic procedures
1. Many signs of systemic disorders, such as diabetes or avitami-
nosis, manifest themselves in mucosal structures; these may indicate
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 the association of
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 be carefully considered in
reference t.o time of treatment, 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 follows
instructions for the use of the prosthesis.
7. The risk of osteoradionecrosis is greater in the mandible than
in the maxillae.
8. Evaluation of the patient’s arch form, cross-sectional shape of
the alveolar ridges, retromylohyoid extensions and tongue position
are important physical criteria for establishing a prognosis.
9. Relief or alteration of the denture base to accommodate
undercuts associated with root eminences of overdenture abutments
may cause reduced retention, stability, and border seal.
10. Patients for whom overdentures are planned should be
informed that overdentures may be less stable and retentive than
fixed or removable partial dentures.
11. Endodontic treatment of an overdenture abutment is usually
required so that the tooth can be reduced sufficiently to allow
esthetic placement of the artificial tooth.
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 foun-
dation 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.
5. Palatal relief should not be routinely placed in the maxillary
complete denture.
6. Artificial anterior porcelain teeth should not be used with pos-
terior 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 expe-
rienced denture patient.
9. Optimum denture retention at denture placement can aid the
patient in learning the neuromuscular control needed to effectively
use complete dentures.
10. Anatomic regions that resist resorptive changes most effec-
tively should be covered to promote long-term support and minimize
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.
JANUARY 1989 VOLUME 61 NUMBER 1
PRINCIPLES, CONCEPTS, AND PRACTICES IN PROSTHODONTICS
11. In preparing overdenture abutments, it is important to reduce
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, and 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 maintenance of hygiene.
14. Although retentive devices can enhance overdenture reten-
tion, they may not be essential for successful patient care.
15. When available, canines are the most desirable teeth to sup-
port 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 labial
or buccal surfaces should be sufficient to allow esthetic positioning
of the artificial teeth.
18. Overdenture abutments aid in providing support and stabil-
ity 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 dentures
are placed. Factors to consider in determining the length of time for
complete tissue rest include the patient’s age, the condition of the
supporting tissue, the length of time the prosthesis has been worn
continuously, and the thickness of the mucoperiosteum.
2. 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.
3. Residual ridge resorption under complete dentures may al-
ter occlusal relationships, which can further hasten ridge resorp-
tion.
4. For overdenture abutments, periodontal health should be es-
tablished and maintained. Proper education of the patient in the
maintenance of the teeth and denture are important. Daily,
the patient should clean the teeth under the denture and apply flu-
oride.
D. Impressions
1. There is a relationship between the requirements for an ade-
quate impression and the contemplated external form of the pros-
thesis. Before the impression procedure is started, a concept of the
completed denture border form should be developed. This is deter-
mined from the diagnostic cast and by visual and digital examina-
tion of the denture-bearing area, including the tongue’s influence 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 man-
dibular impression should include the entire residual ridge and the
retromolar pad and extend lingually into the floor of the mouth in-
cluding the retromylohoid fossa. The distobuccal extensions should
include the external oblique ridges and should approach the ante-
rior borders of the rami.
3. Final impressions should record the entire denture foundation
area to be covered by the denture base.
4. The foveae palatinae are anatomic landmarks that can be used
as one aid in determining the posterior limit of the maxillary den-
ture.
5. The location of the junction of the movable and immovable soft
THE JOURNAL OF PROSTHETIC DENTISTRY
palate is used to determine the posterior extension of a complete
maxillary denture.
6. The curved borders of the labial, buccal, and lingual areas of
final impressions represent the extension and contours to be repro-
duced in the processed prosthesis.
7. Areas of the impression tray that may exert excessive pressure
on the denture foundation area should be determined and relieved
before an impression is made.
8. Impressions of edentulous arches should record the form of
healthy tissue at rest and extend to the physiologic limit of border
tissues to maintain a border seal and to assure the distribution of
functional stresses 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 ingress
of air between the denture base and soft tissue. These physical fac-
tors 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 sus-
ceptibility to pressure-induced resorption.
E. Casts
1. Complete denture impressions should be boxed before pouring
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 maxillomandibular records
1. The incisal length of maxillary occlusion rims should be
established after the desired contour of the facial surfaces has
been set.
2. To prevent displacement of the 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 neuro-
muscular control is good, the residual ridges are ample, and the soft
tissues are not highly displaceable.
4. Methods for recording maxillomandibular relationships in-
clude the following:
(a) Interocclusal records
(b) Mechanical devices
(c) Chew-in techniques
(d) Cephalometric radiographs
5. The recording of centric relation at the correct vertical dimen-
sion of occlusion is one of the most important factors in complete
denture 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 are mounted on the transverse
horizontal hinge axis on an appropriate articulator.
8. The vertical dimension of occlusion usually should be estal-
ished before the centric relation record is made.
9. Centric relation records should be verified regardless of the
posterior tooth form that is used.
10. A facebow is important when any change in the vertical
dimension of occlusion is anticipated during therapy. Such changes
in vertical dimension include the following:
(a) Compensation for interocclusal record thickness
(b) Excuraive movements when cusped teeth are used
(c) Alterations in the vertical dimension of occlusion, including
occlussl adjustment
11. An anatomic average transverse horizontal axis is generally
acceptable for tissue-supported or tooth- and tissue-supported
103

prostheses in determining posterior reference points for a facebow
record.
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 man-
dibular jaw position and occlusion anteriorly.
4. The vertical and horizontal jaw relations of the natural teeth
should be evaluated before immediate denture service is initi-
ated.
5. When a vertical overlap of the anterior teeth is necessary, suf-
ficient horizontal overlap is desirable to prevent interference by the
teeth when the patient is speaking and masticating.
6. The occlusal plane should be located according to mechanical
requirements for stability of the dentures, masticating efficiency,
preservation of the supporting structures, anatomic landmarks, es-
thetics, and phonetics.
7. The stability of the denture bases supporting artificial teeth is
important in maintaining a previously created balanced articula-
tion.
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 poten-
tial for bone resorption beneath immediate or conventional com-
plete 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. Complete dentures should not be relined until existing mal-
occlusion, which frequently occurs after residual ridge resorption,
has been corrected.
14. The proper use of a semiadjustable articulator is advanta-
geous in complete denture construction.
15. An adequate occlusal scheme can be developed for complete
dentures on a semiadjustable articulator.
16. Before fabrication of single complete dentures, the opposing
natural teeth should be restored or recontoured to favorable occlusal
H. Try-in and verification procedures
1. Any treatment sequence for complete dentures should include
a try-in of artificial teeth with stable denture bases to evaluate 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. It is difficult to properly assessthe correct vertical dimension
of occlusion before all teeth are arranged on the denture base.
3. Enunciation of sounds is diagnostically more accurate with
trial dentures than with wax rims.
4. Aging, physical limitations, previous dental history, and lack of
neuromuscular coordination may combine to render the absolute
verification of maxillomandibular relationships impossible.
5. Verification of centric relation and securing eccentric records
should follow verification of the accuracy of the vertical dimension
of occlusion.
6. After the try-in appointment, teeth should be repositioned for
optimal contacts in the centric relation and eccentric positions with
care to avoid altering the appearance of the dentures.
104
ACADEMY OF DENTURE PROSTHETICS
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 that oppose natu-
ral teeth or gold restorations may cause undesirable wear of the op-
posing teeth.
4. The dentist should understand the role of the various denture
base materials and their influence on supporting tissues.
J. Esthetic considerations
1. The relationship of artificial teeth to each other in the arch af-
fects the apparent size and color of individual teeth. Placing a tooth
more anterior in the arch creates the illusion of a lighter shade and
a larger tooth. Placing the tooth more posterior in the arch creates
the 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 positioning
the maxillary anterior artificial teeth too far palatally.
K. Initial placement
1. Complete dentures should be remounted in a semiadjustable or
a fully adjustable articulator for correction of occlusal discrepancies
after initial adjustment of the tissue surface of the denture.
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 in-
traoral occlusal correction.
3. During the initial placement of complete dentures, the dentist
should evaluate border extensions, border seal, retention, and
esthetic values. Areas where the denture exerts excessive pressure
on the denture foundation area should be located and relieved.
4. Surfaces of porcelain teeth that have been ground during oc-
clusal adjustment should be polished.
5. To reinforce previous educational efforts, the patient should
receive verbal and/or written instructions at the initial placement
appointment 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 at least several hours during each 24-hour
period. This is best accomplished during sleep.
7. A record of the vertical dimension of occlusion should be made
at initial denture placement for future reference.
8. Patients should not be given removable restorations before oc-
clusal discrepancies are eliminated.
9. Instructions to overdenture patients must emphasize the im-
portance of meticulous daily cleansing of retained overdenture
abutment teeth, and the importance of the daily use of fluoride
(nonacidulated) in the denture over the abutment teeth.
L. Care after placement
1. Some adjustments of the tissue surfaces of processed resin
dentures should be expected during the early wearing period.
2. Complete denture treatment should include provision for ad-
justment appointments after initial placement of the dentures.
3. Complete denture patients should be informed that they
should be examined at least annually to determine the health of oral
tissues and the condition of dentures. The importance of these fac-
tors should be stressed to each patient.
4. Patients should be advised and reminded that complete den-
tures require periodic adjustment and eventually will require mod-
ification, which may include relining or remaking if proper tissue
adaptation and occlusion are to be maintained.
JANUARY 1989 VOLUME 61 NUMBER 1
PRINCIPLES, CONCEPTS, AND PRACTICES IN PROSTHODONTICS
5. When dentures are initially placed and at subsequent appoint-
ments, the dentist should emphasize the importance of maintaining
adequate hygiene 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. The possible deleterious effects of a complete maxillary den-
ture opposed by mandibular anterior natural teeth and a distal-ex-
tension removable partial denture should be carefully explained to
the patient. The need for frequent examination, continuing treat-
ment when necessary, and removal of both dentures before sleeping
should be emphasized.
10. The proper relining of complete dentures requires skill and
meticulous care.
11. Alteration of the vertical dimension of occlusion should not
occur during relining unless it is required to restore proper vertical
dimension.
12. Relining of complete dentures must include restoration of
proper occlusion. This may require a clinical remount procedure af-
ter the reline and before seating the denture.
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. Immediate and interim restorations
1. Immediate or transitional dentures are the desired method of
treatment for introducing patients to complete dentures. 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. Unnecessary removal of bone should be avoided when teeth are
extracted for placement of immediate dentures.
4. Immediate denture treatment is time-consuming and exacting.
5. The patient should return to the dental office at stated inter-
vals after the immediate denture has been placed so that border ex-
tensions, occlusion, and tissue irritation can be evaluated and
needed corrections made.
6. The immediate denture or one that has been constructed soon
after extraction of the remaining teeth must be maintained with
additions and subtractions for the entire healing period. Eventually,
relining, rebasing, or refabrication of the denture will be necessary.
7. The use of successive temporary relines for immediate com-
plete dentures is recommended to maintain support, stability, com-
fort, and function during the healing period before definitive relin-
ing or secondary denture treatment.
8. When it is desirable to duplicate the arrangement of the nat-
ural teeth, the teeth should be removed from the cast one at a time
so that remaining adjacent and contralateral teeth serve as guides
for positioning of each artificial tooth.
9. The vertical and horizontal jaw relations established by the
natural teeth should be evaluated before implemention of immedi-
ate 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 commonly are 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 obtained after healing.
THE JOURNAL OF PROSTHETIC DENTISTRY
(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 dentures
for initial placement and during the healing period is recommended.
Better quality secondary dentures can be constructed on completely
healed supporting tissues.
15. Before fabrication of a conventional immediate denture is
begun, all posterior teeth are extracted except those necessary to
provide adequate occlusal contacts to maintain the interarch dis-
tance.
16. A transparent surgical template may be used as a guide to the
amount of surgery required during placement of immediate den-
tures.
VI. Implant restorations
A. Diagnostic information
1. The clinical evaluation of a patient requiring implant
prosthodontic treatment should include dental, medical, and
surgical histories. Speech and psychological 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 successof dental im-
plants.
B. Diagnosis
1. A need for an implant-supported prosthesis should be estab-
lished as an alternative to conventional denture therapy.
2. Patients who are to be treated for endosseous dental implants
should have diagnostic casts articulated with a trial arrangement of
artificial 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 sup-
port the implant.
4. An analysis should be made of attached and nonattached gin-
giva 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 sur-
gery.
C. Prognosis
1. The patient should be informed of benefits, risks, time, cost of
treatment, and alternative treatments.
2. Meticulous sterile surgical techniques are essential to the ini-
tial 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 that could cause an unfavorable force distribution and
compromise oral hygiene.
5. Future health changes could change the prognosis for survival
of an implant restoration.
D. Prerestoratiue treatment
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.
105

3. Before proceeding with treatment, patient response to educa-
tional-efforts should be assessed.
4. If an interdisciplinary team provides treatment, one member
(usually the restorative dentist) must supervise and direct treat-
ment.
E. Prosthodontic treatment
1. Dental implants may be classified as subperiosteal, endodon-
tic, endosteal, transosteal, intramucosal inserts, supraperiosteal or
subperiosteal augmentation.
2. Fixed, removable, fixed-removable, and overdenture prosthe-
ses can be used with dental implants. The prosthesis must match the
implant capabilities.
3. Casts for diagnosis and/or custom implant design and fabrica-
tion 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 non-
irritating materials. All particles of impression material must be re-
moved from the bone surface and tissue after removal of the
impression.
5. A totally implant-supported prosthesis does not depend upon
soft tissue for support. The impressions need 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 accord-
ing to accepted principles for optimal support, extension, and sta-
bility for tissue-borne prostheses.
7. It is the dentist’s responsibility to design the implant-sup-
ported restoration.
8. An immobile occlusal record base facilitates obtaining accurate
and verifiable maxillomandibular relation records.
9. Fixed, fixed-removable, removable partial, removable com-
plete dentures, and overdentures in implant dentistry have varied
occlusal requirements. The occlusion should be developed to reflect
the prosthodontic capabilities of the dentist, the available support,
and the needs of the patient.
10. Occlusal patterns should be developed to direct forces to the
regions selected for stress distribution.
11. All implant-supported restorations should seat passively over
implant abutments.
12. Overdentures supported completely by implants may not re-
quire border extensions or palatal coverage to the same extent as
conventional complete dentures.
13. The patient must be informed of the need for continued reg-
ular maintenance.
14. Diligent home care is necessary with periodic professional
maintenance.
F. Materials and devices
1. The dentist should be aware of the implant type, number, de-
sign, and stress distribution to the surrounding tissues when plan-
ning the prosthesis.
2. Materials and techniques must be biocompatible.
G. Interim restorations
1. Immediate restorations on endosseous implants may or may
not be placed dependent upon modality and concepts.
2. Interim restorations may consist of removable complete den-
tures, removable partial dentures, or fixed prostheses depending
upon the implant supported and system used.
3. Interim dentures for osseointegrated dental implant patients
should be periodically relined with soft lining material during the
healing period to prevent trauma to the implant sites.
106
ACADEMY OF DENTURE PROSTAETICS
MATERIALS AND DEVICES
A. Articulators
1. An articulator is a mechanical device that represents temporo-
mandibular joints and the jaw members to which maxillary and
mandibular casts may be attached to simulate some or all of the
mandibular movements.7
2. The ideal articulator should be capable of reproducing all the
patient’s jaw movements during function and parafunction and
should maintain the mounted relationship of the opposing casts.
3. The use of an articulator is essential in most types of pros-
thodontic care.
4. An articulator is no more accurate in reproducing mandibular
movements than the records employed to adjust the instrument.
5. The types of articulators can be classified as simple hinge, av-
erage value, semiadjustable, fully adjustable, and fossae molded.
6. Simple hinge articulators can be accurate in centric occlusion
when caste are mounted at the correct vertical dimension of occlu-
sion. Eccentric positions cannot be reproduced; changes in the ver-
tical dimension of occlusion accomplished on the articulator inval-
idate the centric occlusion.
7. Average value articulators have the same limitations as simple
hinge articulators, but will permit minor changes in vertical dimen-
sion of occlusion if a traverse horizontal-axis facebow is accepted by
the articulator and utilized. Eccentric positions only approximate
the patient’s eccentric positions.
8. Semiadjustable articulators used with a kinematic face-bow
and eccentric records allow centric relation records to be mounted
at an increased vertical dimension, minor changes in vertical
dimension, and a closer approximation of the patient’s mandibular
movement at the end points of eccentric movement than when an
average value articulator is used.
9. A fully adjustable articulator or fossae molded articulator,
when provided with the proper kinematic records and programming,
will encompass all of the features of the semiadjustable articulator.
It also will closely approximate the patient’s mandibular 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 contacts
of completed restorations.
12. The adjustable guidances of an articulator should permit al-
teration to harmonize with the recorded and/or anticipated man-
dibular movements.
13. The anterior guide of an articulator should be adjustable
and/or have a provision for custom guide fabrication.
14. A facebow record should be used for mounting the maxillary
cast on an articulator that will accept an axis transfer.
15. An occlusal scheme developed on any articulator should be
clinically evaluated in the mouth before a prosthesis is finalized or
luted in place.
16. A fully adjustable articulator or technique giving equivalent
accuracy is desirable when extensive fixed occlusal restorations are
planned.
17. The dentist should know the limitations of the articulator
being used and how to compensate for them.
18. A third point of reference is important in a facebow transfer
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
JANUARY 1989 VOLUME 61 NUMBER 1
PRINCIPLES, CONCEPTS, AND PRACTICES IN PROSTHODONTICS
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 temporomandibular 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 facil-
itate osseous healing and to help maintain the vertical dimension of
occlusion after posterior teeth have been removed.
5. Interim restorations may be desirable before placement of en-
dosseous implants:
(a) To maintain function and appearance during postsurgical
healing phase
(b) To aid in presurgical planning of the location and angula-
tion of implants
6. Interim restorations should be used in 6xed prosthodontics
when the vertical dimension must be restored and dental esthetic
requirements determined.
7. An interim prosthesis may be constructed to aid in stabilizing
the dentition during periodontal treatment.
8. Interim restorations should meet all guidelines for restorations
with regard to periodontal health, esthetics, and function. They
should stabilize the occlusion and position of the remaining teeth.
Where lost vertical dimension of occlusion is to be restored, the in-
terim restoration can verify this occlusal dimension so that it can be
restored in harmony with oral facial function.
AUXILIARY PERSONNEL, WORK
AUTHORIZATION, AND LABORATORY
UTILIZATION
A. Auxiliary personnel
1. Clear, concise communication among all members of the den-
tal health team enhances the quality of the dental service received
by a patient.
2. Auxiliary personnel may aid the dentist in obtaining diagnos-
tic information for treatment planning purposes.
3. Delegation of specific procedures to qualified auxiliaries is ac-
ceptable where legally permissible; however, the dentist is respon-
sible for treatment within the framework of liability established 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 prostho-
dontic team. Communication between the technician and the den-
tist enhances the patient’s treatment.
6. The skills and training of the dental technician should be rec-
ognized and properly used as an adjunct to improve the quality of
the finished restorations.
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.
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, as well as the dental assistants and dental
technicians, should prevent contagious disease contact and trans-
mission. They should be immunized, sterilize instruments, impres-
sions, and casts; disinfect environmental surfaces; and use gloves,
protective eye wear, and face masks.
THE JOURNAL OF PROSTHETIC DENTISTRY
12. When indicated, a dentist, physician, or nutritionist should
provide the patient with nutritional advice.
B. Specific to mazillofacial prosthetics
1. Facial prostheses may be fabricated with patient contact by a
prosthetist under the supervision of a prosthodontist.
C. Work authorization and laboratory utilization
1. A properly executed work authorization can be an effective way
for the dentist to communicate with the dental laboratory techni-
cian.
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. Specific work authorization by the dentist is essential to pro-
vide quality control during the laboratory phase of prosthesis fab-
rication.
4. The dentist should provide a completed work authorization
form that 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 properly mount
casts in an articulator and are the dentist’s responsibility.
6. The dentist must provide the laboratory with adequate diag-
nostic caste, 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 ar-
tificial teeth.
9. The flasking of a removable prosthesis in artificial stone or
other suitable material should be done in sections to facilitate sep-
aration 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 using a diagnostic cast to design the restorations.
11. The dentist should request that the metal ceramic framework
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 compli-
cated, a framework try-in should be requested. Framework try-ins
of extensive ceramic restorations should be routine.
13. Direct dentist-technician communication is necessary when
working with ceramic restorations, and an appropriate method of
communication should be employed to facilitate final shading and
staining.
LEGAL CONSIDERATIONS
A. Basic to all prosthodontics
1. The laws of each jurisdiction are different and, although this
is written with generic law in mind, laws that 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 per-
form, or not to perform, some legal act.
3. Except in special situations, usually not related to the dentist-
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 be-
tween the parties was reached.
5. The terms of a contact may be expressed or implied.
107

6. Terms that usually are expressed include the fee, nature of the
treatment to be performed, the time in which the treatment is to be
completed, payment arrangements, and 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
implied warranties of fit and satisfaction, the courts have ruled
against such warranty.
9. The courts have consistently held that the fee paid for the fab-
rication of a prosthesis is for the service required to complete it, and
not for the physical prosthesis. However, guarantees made 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 il-
legal.
11. Guarantees may result in loss of a suit based on breach of
contqact rather than on malpractice.
12. In a breach of contract suit, negligence need not be shown.
13. In many jurisdictions, unless an express guarantee is made by
the care provider, breach of contract suite 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.
C. The standard of care
1. The standard of care to which dentists are held by courts in
malpractice casesis to provide care using the same degree of knowl-
edge, education, and training that a reasonably prudent dentist
would provide in the same or similar community.
2. 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.
3. Consistent with the definition of the standard of care, special-
ists usually are held to the standards of other specialists, and gen-
eral practitioners are usually held to the standards of other general
practitioners.
4. If one holds oneself as a specialist, although a generalist, the
courts are likely to apply the standards of a specialist.
5. Another risk for the generalist (depending on the quality of
treatment provided) is that if it can be shown that other generalists
in the same community would have referred the patient to a
specialist, not having made the referral could constitute negligence.
6. Generally, it is desirable to limit treatment to aspects of den-
tistry in which the dentist is qualified and competent. The dentist
should make appropriate referrals on a timely basis and maintain his
skills and knowledge consistent with the advances in his field of
practice.
D. Consent
1. It is firmly established that if a doctor treats a patient without
informed consent, he or she ma,y be liable for damages, even if the
treatment benefited the patient.
2. In the landmark cast of Canterbury versus Spence, decided in
1972, the court indicated that for consent to be valid it must be in-
formed. Guidelines were established by which to judge whether the
consent was truly informed.
3. During the past decade, most courts have adopted the Canter-
bury 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 con-
sent determines by expert testimony what other practitioners in the
same community disclose to their patients when faced with a sim-
ilar treatment. The defendant practitioner is held to that measure
of disclosure.
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ACADEMY OF DENTURE PROSTHETICS
5. Another standard of informed consent is the “reasonable per-
son standard.” There are two divergent views expressed by the
courts using this standard: the objective test and the subjective test.
In the former, the measure is: How much would any reasonable per-
son 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 dis-
closure of risks.
7. In jurisdictions that adhere to the reasonable person standard,
the general rule is that risks are “material” and 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 consent.
As an example, New York, by statute, chose the professional com-
munity standard.
10. Many courts have distinguished between total lack of consent
and inadequate disclosure in obtaining consent. The former may be
considered as assault and battery. In the latter, the dentist is neg-
ligent 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 consent
cannot 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
the 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, or to the pa-
tient signing a separate form with a copy 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. The best the practitioner can do, with respect to legal risks,
is to take precautions to weight the odds in his or her favor.
E. Patient records
1. In some jurisdictions, the law requires that accurate records of
the diagnosis and treatment of a patient be maintained as part of
care.
2. In the eyes of the law, good records are as important in patient
care as the diagnosis and treatment.
3. Failure to keep accurate records may result in penalties
imposed by the state if the requirement to maintain records is man-
dated by law, a finding of negligence by a court in a civil suit brought
by a patient, or loss of a malpractice suit because the defendent
dentist was unable to document the care provided.
4. Entries on the patient’s treatment record may become public
information. Keep in mind that the record may eventually be seen
and subject to review by the patient and his or her attorney.
5. For complete protection, if the records are required for the de-
fense of an allegation of malpractice, they should be kept indefi-
nitely.
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, never part with
the original record, radiographs, consultation 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 patient’s records.
JANUARY 1989 VOLUME 61 NUMBER 1
PRINCIPLES, CONCEPTS, AND PRACTICES IN PROSTHODONTICS
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 as to the
patient’s mental state should be avoided.
14. In many jurisdictions, the patient may have access to dental
records. If you are sued, do not record conversations with any attor-
ney or representatives of the insurance company on the treatment
record. Place such notes in a separate file.
15. It is best not to include financial information on the treatment
record. Such data should be kept separately.
16. Never tamper with the records. Fraud may be suspected if
treatment records appear to have been tampered with.
17. The patient’s record is a legal document.
F. Associates and employees
1. In partnership practice, each innocent partner may be held ac-
countable for the negligent act of any other partner.
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.
3. An employer is liable to an injured party for the negligent acts
of an employee.
4. An employee of a dentist becomes the agent of the dentist in
dealing with patients.
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 the dificult patient and issues of abandonment
1. There are situations in which discontinuing treatment is the
only reasonable alternatives to predictable failure in care; for exam-
ple, when patient fails to cooperate in his or her care, to keep
appointments, or to live up to financial agreements. If the dentist
cannot function effectively under such circumstances, the patient
should be so informed.
2. To help health practitioners avoid being found guilty of aban-
donment, the courts have provided the following guidelines:
THE JOURNAL OF PROSTHETIC DENTISTRY
(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.
(cl Cooperation in the treatment should be assured by the
substitute dentist.
(d) All records and radiographs relating to the patient’s treat-
ment should be made available to the substitute dentist
upon request.
3. In notifying the patient of an intention to discontinue treat-
ment, remember that it is in the patient’s best interest and that the
patient should be advised to seek the services of another dentist.
4. After telling the patient of a decision to discontinue treatment,
a certified letter with return receipt required should be sent. 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 Academyof DentureProsthetics.Principles,concepts,and practices
in prosthodontista.J PROSTHET DENT 1959;9:528-38.
2. The Academyof DentureProsthetics.Principles,concepts,and practices
in prosthodontics.J PROSTHET DENT 1960,10:804-6.
3. The Academyof DentureProsthetics.Principles,concepts,and practices
in prosthodontics.J PROSTHET DENT lS63;13:283-94.
4. The Academyof DentureProsthetics.Principles,concepts,and practices
in prosthodontics-1967. J PROSTHET DENT 1968;19:180-98.
5. The Academyof DentureProsthetics.Principles,concepts,and practices
in prosthodontics-1977.J PROSTHET DENT 1977;37:204-21.
6. The Academyof Denture Prosthetics.Principles,concepts,and practices
in prosthodontics-1982. J PROSTHEYTDENT 1982;48:467-84.
7. The Academyof DentureProsthetics.Glossaryof prosthodonticterms.J
PROSTHET DENT 1987;58:713-62.
REPRINTS
Reprints of the seventh edition of the Principles, Con-
cepts, and Practices in Prosthodontics are available from the
Education and Research Foundation of Prosthodontics.
Send to Dr. John B. Holmes, 279 Sandringham North, Mor-
aga, CA 94556.
109