Rev.

12/11

University of Connecticut School of Dental Medicine Department of Reconstructive Sciences

Prosthodontics Clinic Manual

Rev. 12/11

Clinic Protocols
I. Session Information
Clinic sessions begin promptly at 9:00AM every day and 1:00PM on Mondays, Tuesdays and Fridays or 2:00PM on Wednesdays and Thursdays. At the very beginning of each session, the student is expected to have their assigned operatory set up with all the equipment and supplies needed to accomplish their goals for that session. If the student is uncertain as to what equipment and supplies are needed for a particular procedure, he/she should refer to the course manual for that discipline. Cassettes are not to be opened until the patient has arrived to the clinic. For any given clinic session, the student may not begin patient treatment until consulting with prosthodontic faculty. No exceptions. Patients should not be dismissed without faculty approval. Violation of this policy may result in loss of clinic privileges. Patients should never be in the clinic without a faculty member also present in the clinic. Patients must be dismissed by 11:45 in the morning and 4:45 in the afternoon session. This allows 15 minutes for students to clean-up, return equipment to the dispensary, and complete chart entries and computer work by 12:00 for the morning session and 5:00 for the afternoon session. The timely dismissal of patients must be adhered to when crowns and fixed prostheses are brought to the Prosthetic Laboratory for final glazing or polishing. In order to ensure this, crowns and fixed prostheses must be submitted to the lab with a faculty signed prescription no later than 10:45 in the morning and 3:30 in the afternoon. If a restoration is taken to the laboratory later than these deadlines, the provisional must be recemented and the patient scheduled for a separate delivery appointment.

II. Working with Faculty

The student may work with a number of different clinical preceptors for each patients overall treatment plan. By not limiting the student to working with the same clinical preceptor for each visit, patients can be scheduled at the convenience of the patient and student. There may be exceptions when it is in the patients and students best interest to work with the same preceptor for a certain phase of treatment. One example is complete dentures. It is helpful to work with the same preceptor for the wax try-in visits due to the subjective nature of esthetics. Prosthodontic Residents: Occasionally, prosthodontic residents will help cover the predoctoral clinic. The residents may sign a students daily progress notes, but they may not provide signatures for treatment plans or for submitting lab work to the prosthetic lab.

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III. Infection Control

Proper infection control procedures must be accomplished before and after the clinical procedure for each patient. All impressions, interocclusal records, crowns, prostheses, facebows and articulators (when necessary) must be properly disinfected before they are removed from the clinic. In addition, all materials that have been worked on outside of clinic must be disinfected if they will be used in direct patient care (e.g., denture bases, record bases, facebows, etc.) Students must pay close attention to what they are touching with gloved hands that have been in the patients mouth. Many students are seen adjusting masks, glasses and hair with dirty gloves. Students are also observed adjusting glasses, masks, hair, etc. with clean gloves. These gloves should not be used in the patients mouth! Be aware of cross-contamination either way. Infractions of the infection control policy will result in corrective action.

IV. Clinic Supplies and Equipment

At the beginning of each clinic session, the student may obtain needed equipment and instruments from the Dispensing Room. At the completion of treatment, all instruments and equipment should be scrubbed clean before returning these items. If a student removes supplies or equipment from a Clinic Dispensing Room without permission from the Lead Dental Assistant and/or without recording their name and the item on a "sign out sheet", or if any borrowed items are not returned to a Clinic Dental Assistant within 24 hours, the student will not be permitted to treat patients in Clinic until the borrowed item is returned or replaced.

V. Student Preparedness for Clinic Sessions

Students must be prepared for each session in prosthodontics. Students should not rely solely on the faculty to take them step-by-step through each procedure. The student is responsible to arrive prepared for the session, having reviewed the previously presented material from the relevant preclinical course. Although the faculty do not expect the student to work without any guidance, students are expected to have an understanding of the steps involved and a plan for what needs to be accomplished in given session. For example, if the student is delivering a crown, then the student must know the correct sequence of procedures, know the appropriate instruments to use, and know the various materials to be used (especially the cement.)

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V. Student Preparedness for Clinic Sessions, cont

If a student is unprepared for clinic and demonstrates a lack of understanding of the days procedure that would jeopardize his/her patients safety, then faculty member may have the student send the patient home without treatment and the student will receive a failing grade for that session. Additionally, various corrective actions may be required by the faculty to address the areas where the student is lacking in understanding or basic knowledge. Students may be asked to write a relevant topic paper, perform remedial typodont work or complete other relevant laboratory exercises. If the student does not complete these requirements adequately, then the student may be removed from clinical activity until corrective actions have been effectively addressed.

VI. School-wide Payment Policy

Patients must pay 50% down PRIOR to the start of any prosthodontic procedures. This includes complete dentures, RPDs, fixed, and implants. There has been a misconception that half down is only necessary when the student is ready to submit the prosthetic work to the lab. The patient must be making the half down payment prior to the start of the prosthetic procedure. The white PSR slip must be presented to the faculty prior to the start of any procedures that will have a laboratory component. This will confirm that the patient has made the appropriate payment. This is necessary whether the patient is self-pay or Title 19. NOTE: If the treatment is to be a cast post and core, then the patient must pay in full for the cast post and core and pay half down for the crown on the same tooth.

VII. Quadrant Dentistry

Students are to treat only one quadrant at a time with fixed prosthodontics. This means that a patient should not have provisionals in more than one quadrant at any given time. If there is a perceived need for an exception to this policy, then the student must have signed approval in the chart from Dr. Duncan. Failure to comply with this policy may result in loss of clinic privileges or other disciplinary action. Please review any treatment plans that will require the removal of multiple existing crowns with Dr. Duncan or Dr. Taylor before proceeding. Crowns that need to be removed to determine a tooths restorability should be done at the end of Phase 1 treatment. If these existing crowns are in multiple quadrants, the student MUST review the treatment plan and sequence of treatment with Dr. Duncan or Dr. Taylor before removing any crowns.

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VIII. Prosthodontic Open Hours

Prosthodontic Open Hours are held on Wednesdays from 12:00 to 2:00 in the Reconstructive Sciences Conference Room (L6105) on the 6th floor. All available prosthodontic faculty are present to answer questions. Students are encouraged to take advantage of this time to discuss treatment plans, design RPDs, review lab work for submission, and answer any questions that they might have relative to prosthodontics and beyond. If, for some reason, Open Hours are cancelled, students will be notified via email. Students must NOT skip classes or mandatory meetings in order to attend Open Hours. Students must NOT seek out faculty in University Dentists or CIRD for signatures. This is the facultys private practice time, and students should not interrupt faculty in these settings.

IX. General Prosthetic Laboratory Protocol and Quality Control

All prosthetic work submitted to the prosthetic laboratory must be first signed by the faculty member with whom the student was most recently working whenever possible. (For example: Complete dentures should be signed by the faculty with whom the student did the final esthetic try-in. Fixed work should be signed by the faculty with whom the student made the final impression.) Cases will not be reviewed without appropriate student and faculty signatures on submitted cases. Once signed by the appropriate faculty, the student will bring the case to the prosthetic lab. Cases are logged into the lab, reviewed by prosthodontic faculty for Quality Control, assigned to a technician and given a return date. During the processing period, student cases may be in various locations either inside or outside of the Prosthetic Laboratory. Students are encouraged to "check up" on the progress of cases submitted. If the case does not pass through Quality Control, the laboratory will contact the student. Be advised that laboratory work does not commence for approximately two days (sometimes a bit longer than two days) after the student brings a case into the lab. Students are encouraged to work closely with the dental technicians in our prosthodontic laboratory so that they are able to see cast restorations and removable prostheses in various stages of fabrication.

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X. Patient Situations that are Unacceptable for Care in the Undergraduate Clinics
Patients are routinely screened for acceptance into the dental school. Patients that are not appropriate for care in the students clinics due to the complexity of their treatment needs should be referred to the appropriate graduate clinic. The following is a list of patient situations that are not appropriate for the undergraduate clinics. 1. Patients exhibiting evidence of severe tooth abrasion, attrition, and/or bruxism. 2. Dentate or partially dentate patients exhibiting evidence of collapse/loss of vertical dimension of occlusion that will need to be increased either with fixed or removable partial dentures. 3. Patients for whom it can be anticipated that a mandibular immediate complete denture is the most likely treatment option. Mandibular immediate dentures are not done in the predoctoral clinic. 4. Patients with conditions that affect the entire dentition or result in multiple missing teeth in young individuals. These include multiple dental agenesis, amelogenesis and dentinogenesis imperfecta, and ectodermal dysplasia. 5. Patients needing maxillofacial prostheses such as obturators, speech appliances, palatal lifts, etc. 6. Patients requiring removable prostheses who have a history of therapeutic radiation therapy to the head and neck. 7. Patients presenting with root resected teeth in need of restoration. 8. Patients with severe mental or emotional problems that would make them difficult to manage for beginning students. 9. Patients desiring extensive and complex esthetic procedures such as multiple (more than 4) esthetic veneers. 10. Patients who may require overdentures on natural teeth (with or without attachments.)

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XI. Prosthodontics at Comminity Health Center Rotations

1. Students may receive up to 2 units of experiential fixed credit for crowns or bridges complete at their community health center rotation. The student must have completed all phases of treatment (prep, temp, impress, delivery) in order to receive credit. The student must submit a form signed by the site faculty for verification. This form can be found at the end of this manual. 2. Complete dentures and removable partial dentures may be done at community health center rotations; however, they will not count toward the students minimal essential experiences. Due to the small number of removable experiences, it is the facultys desire to have direct interaction with the student in these cases to reinforce the principles taught during the preclinical removable courses. 3. If a student has the opportunity to make a removable partial denture at CHC, then the student must bring the patients diagnostic casts to Open Hours in order to design the framework. Again, the faculty would like the opportunity to reinforce the RPD principles taught in preclinic. This will not occur when designing frameworks with CHC site faculty.

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Diagnosis, Treatment Planning & Sequencing Prosthodontic Treatment

I. Data Collection Visit in Prosthodontics
The objectives for data collection sessions in clinic are for the student to: 1. Examine the patient and record data required for the complete assessment of prosthodontic needs. The Operative Dentistry Worksheets can be used with dentate or partially dentate patients to help record this data. Prosthodontic Worksheets can be used to guide the examination of edentulous patients and/or make a tentative treatment plan and/or RPD design when needed. Worksheets are not, however, to be attached to the patient record. 2. Make alginate impressions, interocclusal records and a facebow transfer to generate mounted diagnostic casts when indicated. Mounted diagnostic casts are required for all patients you are treatment planning for tooth replacement with fixed or removable partial dentures. Mounting of the casts is not necessary for complete denture patients unless significant alveoloplasty is indicated. 3. Establish or begin to establish a detailed sequential treatment plan including needed prosthodontic treatment. NOTE: Once a prosthodontic faculty member has reviewed the patient data with the student, then the faculty member should sign the prosthodontic box in the patient record (Section IV--Exam and Treatment Planning Log). The left side is signed after the patient data is reviewed. The right side is signed after the approved, and appropriately sequenced, treatment plan has been printed out and reviewed by the faculty member. Faculty should not sign both boxes without reviewing the printed treatment plan. Prosthodontic treatment plans may only be signed off (right side box) by full-time prosthodontic faculty. Part-time faculty or residents may not sign off

treatment plans.

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II. Sequencing Prosthodontic Treatment

General Considerations: 1. The sequence of treatment should be dependent upon the particular needs of the patient. Priority should be given to establishing and/or maintaining a solid posterior occlusion before addressing anterior crowns or veneers. 2. Endodontically treated teeth should be restored with a core buildup, a cast post and core and a provisional crown, or a final direct restoration maintaining occlusal and proximal contact soon after endodontic therapy is completed. To this end, cast post and cores may be included in Phase I treatment. 3. All fixed partial denture cases must have mounted diagnostic casts on a semiadjustable articulator with a diagnostic wax-up. The diagnostic wax-up of the FPD must be reviewed and approved by faculty before beginning any tooth preparation. This is an extremely important step and there will be no exceptions to this policy. If the student presents in clinic to begin tooth preparation for an FPD, the student must have the mounted casts and wax-up available at that time. If not, the student will be instructed to dismiss his/her patient. 4. Upon completion of the treatment planning process, a tentative RPD design should be drawn on the RPD worksheet, signed by faculty, and placed in the daily treatment notes. The design will be based on mounted diagnostic casts made from initial alginate impressions made during the initial exam. The student should have the mounted diagnostic casts and radiographs available when discussing a design with the faculty. Operative treatment MUST NOT be started without an approved RPD design in the patients chart. 5. For more information on treatment sequencing, the student may refer to the didactic materials provided in the RPD preclinical course. 6. Prosthodontic Open Hours is an ideal time for the student to review complex treatment plans to establish an appropriate sequence and approach to a patients care.

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QR CODES FOR PROSTHODONTICS

FIXED PROSTH CODES 2740 2750 2790 2952 CROWN PORC/CERAMIC CROWN PORC/METAL CROWN FULL CAST METAL CAST POST AND CORE Credit received if attending confirms that student performed sufficient amount of work independently Code for PFM pontics Code for full gold pontics Code for PFM bridge abutments on self pay patients Code for full gold bridge abutments on self pay patients Procedure conveniences MUST be included and signed off in QR as they are completed Code for all ceramic crowns Code for PFM crowns Code for full gold crowns

2962

LAB VENEER PORC

6240 6210 6750

BRIDGE PONTIC PORC BRIDGE PONTIC CAST BRIDGE CRN PORC

6790

BRIDGE CRN CAST

16013

UNDERGRAD SINGLE TOOTH IMPLANT

State patients only: D2750 and D2790 are the only acceptable codes for crowns on State patients.

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REMOVABLE PROSTH CODES

5110 5120 MAX COMP DENTURE MAND COMP DENTURE One must always include a maxillary reline as well in the treatment plan. Relines are NOT included in the cost of immediate dentures. Not done in student clinics! Code to be used when anterior and posterior teeth are being replaced Code to be used when anterior and posterior teeth are being replaced Code to be used when only 3-4 anterior teeth are being replaced

5130

MAX IMMED DENTURE

5140 *5211 *5212

MAND IMMED DENTURE MAX TRANS PART MAND TRANS PARTIAL

*5820 *5821 5213 5214 5410 5411 5421 5422 15000

INTERIM PART DENT MAX INTERIM PART DENT MND MAX PART DENT/METAL MAND PART DENT/METAL ADJ COMP DENT/MAX ADJ COMP DENT/MAND ADJ PART DENT/MAX ADJ PART DENT/MAND RECALL FOR CD/RPDS

Adjustment codes do not generate charge, and they are to be used within the first year of delivery.

One year after delivery, this code should be entered for all denture recalls. It generates a nominal charge.

*Counts toward 1/3 arch of removable if all aspects have been completed by one provider. Additionally, relines or rebases done for conventional dentures that a student has made and that do not fit adequately are not credited as a 1/3 of an arch.

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REMOVABLE PROSTH CODES, cont

5510 5520 5610 5620 5630 5640 5650 5660 *5710 *5711 *5720 *5721 *5750 *5751 *5760 *5761 16014 REPAIR COMP DENTURE REPLACE TOOTH CD REPAIR RESIN PARTIAL REPAIR CAST FRAMEWK REPAIR/REPLACE CLASP PD REPLACE TOOTH PART DENT ADD TOOTH ADD PART DENT CLASP REBASE COMP MAX DENT REBASE COMPMAND DENT REBASE MAX PART DENT REBASEMAND PART DENT RELINE MAX CD LAB RELINE MAND CD LAB RELINE MAX PD LAB RELINE MAND PD LAB UNDERGRAD IMPLANT SUPPORTED OVERDENTURE Procedure conveniences MUST be included and signed off in QR as they are completed

*Counts toward 1/3 arch of removable if all aspects have been completed by one provider. Additionally, relines or rebases done for conventional dentures that a student has made and that do not fit adequately are not credited as a 1/3 of an arch.

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FIXED PROSTHODONTICS
I. Crown and Bridge Restoration Protocol
All foundation restorations on a tooth that will receive a crown must be replaced if: 1. the restoration was done outside the SDM 2. the restoration was done at the SDM >3 years previously For any full gold or PFM crown delivered, an alloy sticker (given to you by the dental laboratory with the final crown) must be placed in the patient record at the time of crown delivery Bridges spanning more than 4 units may NOT be done in the student clinics. The only exceptions may be bridges from canine to canine, in approved cases.

The student MUST present a prepared typodont for any tooth to be prepared for
a crown or bridge in the clinic. For example, if the student will be preparing tooth #3 for a full gold crown during that clinic session, then the student must present a typodont with the same tooth and preparation design to the preceptor before beginning treatment. If the student does not have the typodont

prepared, then the student MAY NOT begin the crown preparation during that session.
Phase I re-evaluation must always be completed prior to the start of any Phase II treatment. Diagnostic casts must be present in clinic with the student whenever fixed prosthodontic work is planned. If the student does not have them, the student will not be allowed to begin a crown preparation until they have been made. Treatment to be rendered MUST be on the treatment plan that has been printed out and signed by the patient. All fixed partial dentures must have a diagnostic wax up or cast duplicating this wax up present for any fixed partial denture procedures. All fixed partial dentures require a multi-unit provisional prior to making the final impression. Example: A patient requires a bridge from 13-15. At the first visit, #15 is prepared and provisionalized. At the second visit, #13 is prepared and a 3-unit provisional is made from 13-15.

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II. Restoration of Endodontically Treated Teeth Note: ALL teeth that require endodontic treatment MUST have a restorability consult with a prosthodontic faculty prior to obturation. All caries must be excavated before the consultation can be done. Also note that the faculty will need to see the tooth in question without the rubber dam in place. General Guidelines:
1. All posterior teeth which are endodontically treated should receive a crown. Anterior teeth which have adequate tooth structure after endodontic therapy may not need to be crowned. This will depend upon the amount of unsupported coronal tooth structure. A prosthodontic consult is recommended at the time of obturation to confirm the need for a crown in questionable circumstances. 2. All endodontically treated teeth do not need to be restored with a post and core. Only teeth with insufficient coronal tooth structure should be considered for a post and core. 3. In general, endodontically treated teeth may be restored with amalgam core buildups, composite core build-ups, or post and cores. Post and cores may be of two types: either prefabricated post and cores or custom fabricated (cast) post and cores. This choice will be specific to the tooth involved and will be made with faculty consultation. 4. A cast post and core should be used primarily for anterior teeth and premolars, and prefabricated posts with amalgam build-ups should be used for molars. 5. Indications for a cast post and core are: a) anterior teeth and premolars b) insufficient tooth structure remaining with no possibility of a 2 mm ferrule c) inadequate isolation for a prefabricated post and composite core 6. Indications for a prefabricated post and core are: a) molars whenever possible b) enough tooth structure remaining to provide at least a 2 mm ferrule (usually no post needed if 2+ walls remain) c) Title 19 patient for whom cast post and cores will not be covered (The option of a cast post and core must be presented to these patients. The benefits and risks of the chosen treatment must be made clear to the patient. Some patients will opt to pay for a cast post and core if it is critical to the long-term prognosis of the tooth.)

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7. For teeth that do not require restoration with a cast post and core (usually molars and sometimes premolars with a significant amount of coronal dentin remaining), gutta percha will remain in the canal(s) and amalgam will serve as a "core" to allow an ideal tooth preparation to be created. The amalgam will be placed directly into the pulp chamber as well as 1-2mm into prepared canal spaces (amalgam-pins). 8. When pre-fabricated posts or custom cast post and cores are to be used to restore a tooth, the post space will be prepared as part of the treatment procedure during post fabrication in the prosthodontic or operative clinic--not in the endodontic clinic. 9. For cases where fixed and removable prostheses are treatment planned, all single crowns that are planned for these cases must be made in the prosthodontic clinic. 10. If a composite core has been placed, then the student must use a resin or resinmodified cement for the final crown. 11. The largest and least curved canal in a multi-rooted tooth is usually the best place to create a post space. 12. The post length should generally be from 1/2 to 2/3 the length of the root, but there should be no less than 4 mm of root filling material left in the apical portion of the canal. 13. When the patient is seen in the Prosthodontic Clinic for fabrication of a custom cast post and core, either an acrylic post and core pattern or an elastomeric impression will be made. These are always done after an adequate post space is made and verified by prosthodontic faculty and the remaining coronal tooth structure has proper axial and occlusal preparation. 14. To make an acrylic provisional restoration combined with a metal post (usually the provisional restoration of choice for a tooth awaiting a custom post and core and crown), please refer to the fixed prosthodontic textbook of choice for a detailed description. 15. The Fixed Prosthodontic syllabus and the fixed prosthodontic course textbook of choice thoroughly describe the post and core try-in, adjustment and cementation procedures. Please be sure to review these procedures prior to arriving in clinic.

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III. Management of "Fixed/Removable" Cases 1. Survey crowns

When "survey" crowns are planned in the same arch where teeth are to be replaced with an RPD, the final RPD design must be on a surveyed diagnostic cast prior to starting any crown preparation. When requesting the fabrication of "survey" crowns from the Prosthetic Laboratory, the path of insertion for the RPD must be indicated on the working cast (cast must be tripoded) and the laboratory work authorization must include directions for the placement of heights of contour (undercuts), guide planes and the size, shape and location of rests on the crowns. Upon receiving "survey crowns" back from the lab, the student must check to see that all of the characteristics noted above are present prior to trying the crown(s) in the mouth. (This means putting the crown on its working cast on the surveyor to be certain that guide planes and undercuts are adequate. Changes cannot be made after the crown is cemented!) The crowns must be cemented prior to making the final impression for the RPD.

2. Crowns or an FPD made opposing or adjacent to edentulous spaces which are to be restored with an RPD
The placement of already-selected denture teeth onto the opposing arch should be included as part of initial diagnostic "wax-up". This allows a matrix to be made over the wax-up which can be used to assess the occlusal reduction needed over crown preparations.

Denture teeth should be set opposing the working cast of the crowns or FPD when submitting these crowns to the lab for fabrication. Denture teeth should be set in edentulous spaces adjacent to dies on the working cast during the fabrication of the crowns or FPD.

3. Crowns or an FPD made opposing a complete denture

When fabricating a single crown, the student may not need to mount the working cast. Please check with a full-time faculty member to verify.

For multiple anterior or posterior crowns, the working cast should be submitted to the lab mounted opposing a cast of the current denture--if not being remade. If the denture is being remade, then the working cast must be mounted opposing either a wax rim that has been evaluated in the patients mouth or a final denture wax-up that has also been verified in the patients mouth. Please note that a final wax up is the most accurate method and is generally recommended. Confirmation with a full-time faculty is advised if the student has questions.

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IV. Communication with the Prosthetic Laboratory

Items to be included with case: 1. 2. 3. 4. 5. 6. 7. 8. mounted working and opposing cast with dies trimmed complete work authorization (as described below) interocclusal record second pour of final impression (i.e., solid cast) articulator final impression diagnostic wax up where appropriate opposing occlusion rim or denture set-up where appropriate (refer to section: Diagnosis, Treatment Planning & Sequencing Prosthodontic Treatment) Guidelines for submitting Fixed Cases to the Laboratory (evaluated by signing faculty and verified by Quality Control faculty) Working dies die(s) correctly trimmed finish line well-defined, and carefully marked with red pencil die(s) stable and seated completely preparation must have sufficient occlusal and axial reduction preparation must have sufficient path of draw/resistance and retention form articulation correct opposing cast in good condition mounted working cast, opposing cast and articulator are neat and clean cases involving bridges or multiple units must be mounted on a semi-adjustable articulator

Articulated casts

Work Authorization whenever possible, should be signed by the preceptor who you made the impression with in clinic preceptor signature is only obtained when all materials are present for evaluation (mounted casts with trimmed dies, solid cast, complete work authorization) cases CANNOT be left on the Quality Control bench without a student and faculty signature all vital information must be included (type of margin desired, type of occlusion desired, shade, etc.)

N.B. The student is expected to bring acrylic post and core patterns (accompanied by a preceptor signed prescription) to the lab for investing and casting ASAP. The student is does not invest this pattern. 17

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V. Items from the Laboratory

Be certain that all items received from the lab are disinfected before proceeding to the patients mouth (this includes both fixed and removable items) All crowns, post and cores and RPD frameworks that do not fit, MUST be returned to the lab. The metals from these items can be reused. They should NEVER be thrown away or given to the patient.

VI. Materials used in Prosthodontics

Students must be familiar with all materials that they are using in clinic to ensure proper handling for patient, student and staff safety. o TEMPORARY CEMENT REMOVER: Provisionals that have been cleaned using temporary cement remover in the lab must be rinsed thoroughly. Any gloves that have contacted the cement remover must be changed. This material is extremely caustic and may cause significant intraoral and extraoral burns if not handled properly. o ACRYLIC MONOMER: Sensible precautions should be taken to prevent monomer spills. Bottles should not be left open or placed on operatory trays where they may be knocked to the floor. Facilities management must be called to properly clean these spills, which creates an unnecessary cost to the clinics. Not to mention, it smells terrible!

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COMPLETE DENTURES
The following outlines all the procedures, materials, preceptor checks and laboratory scripts necessary for fabricating complete dentures. First Visit: Exam, Treatment Plan, Alginate Impressions Bowl, spatula 01 cassette, alginate, green stock trays (adhesive), metal edentulous trays (no adhesive), Dr. Thompson marking sticks

Student provides: Clinic provides:

Procedures to be completed: Review patients medical history (oral diagnosis faculty consult) Review patients dental history and perform intraoral and extraoral exam . When complete, review with Prosthodontic faculty and finalize treatment plan. Bring patient to financial office. Make alginate impressions after the patient has made a half down payment.

First Laboratory Exercises: Denture bases, mounting casts and occlusion rims Procedures to be completed: Pour casts in vacuum mixed yellow stone Trim casts and mark border extensions and post dam in red pencil PRECEPTOR CHECK Carve post dam Prepare wax pattern for bases2 sheets baseplate wax, ends at line at 90 degree angle PRECEPTOR CHECK Seal base pattern to cast, maintaining extension to red line!! PRECEPTOR CHECK Write prescription to lab: Please process denture bases, thank you PRECEPTOR SIGNATURE Fabricate mounting casts and occlusion rims HAVE PRECEPTOR CHECK RIMS AND CASTS AT LEAST THE DAY BEFORE THE PATIENT IS SEEN

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Second Visit: Student provides:

Adjust Denture Bases, Jaw Relationship Records Denture bases with rims and mounting casts, slow speed handpiece, facebow 01 cassette, RDK (removable denture kit), PIP, Dr. Thompson marking stick, acrylic burs, baseplate wax, aluwax, Hanau and Lenk torches, Mould and Shade guides (Ivoclar or Trubyte), water baths

Clinic provides:

Procedures to be completed: Due to the time needed to completely adjust the denture bases properly, begin with the maxillary denture base. When finished, adjust the lip support, incisal edge position, mark midline, select shade and mould for the maxillary anteriors, and do a facebow transfer. This will allow you to do a mini esthetic try-in at the next appointment and complete your jaw relations. IF YOU HAVE TIME, YOU THERE IS NO REASON NOT TO COMPLETE ALL OF JAW RELATIONS AT THIS APPOINTMENT. Adjust maxillary denture base with PIP. PRECEPTOR CHECK Adjust lip support and incisal edge position of upper rim PRECEPTOR CHECK Mark midline Facebow transfer Select shade and mould of teeth (an alginate of existing dentures is helpful) PRECEPTOR CHECK

IF TIME PERMITS: Adjust mandibular denture base with PIP. PRECEPTOR CHECK Determine vertical dimension PRECEPTOR CHECK Centric relation record PRECEPTOR CHECK Prescription to request teeth from the lab: Please dispense (Ivoclar or Trubyte) denture teeth Shade _____ Maxillary anterior mould ________ Mandibular anterior mould __________ Posterior mould _______ (specify if both max and mand are needed) Thank you

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Second Laboratory Exercise: Set Teeth Procedures to be completed: Set maxillary 6 anteriors if jaw relations incomplete.

OR
Set all teeth if jaw relations are completed. If JRR is complete, you should NEVER set ONLY the 12 anterior teeth. If JRR is complete, then set ALL the teeth.

Third Visit: Complete Jaw Relationship Records/Esthetic Try-in Student provides: Articulator with maxillary cast mounted and 6 anteriors set, mandibular denture base, handpiece (Remember: If JRR was complete at last visit, all teeth must be set!) 01 cassette, RDK (removable denture kit), PIP, acrylic burs, baseplate wax, aluwax, Hanau and Lenk torches, Mould guides, water baths

Clinic provides:

Procedures to be completed: Adjust mandibular denture base with PIP PRECEPTOR CHECK Evaluate esthetics of maxillary anteriors PRECEPTOR CHECK Determine vertical dimension PRECEPTOR CHECK Centric relation record PRECEPTOR CHECK

Third Laboratory Exercise: Set Teeth Procedures to be completed: Finalize tooth arrangement, wax contours should be smooth and teeth wax free Articulator should be clean

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Fourth, (etc.) Visit: Esthetic Try-in Student provides: Clinic provides: Articulator casts mounted and all teeth set, handpiece 01 cassette, RDK (removable denture kit), acrylic burs, baseplate wax, aluwax, Hanau and Lenk torches, water baths

Procedures to be completed: Evaluation of esthetics and phonetics of anteriors Evaluation of vertical dimension Verify centric relation (you must know how to do this procedure!!) Fourth, (etc) Laboratory Exercise: Set Teeth Procedures to be completed: When ready to submit to lab: For monoplane posterior teeth, need bilaterally even contacts with teeth contacting intimately articulator clean wax contours smooth teeth wax free Prescription to laboratory: Please beautify wax up Process, finish and polish dentures Thank you Preceptor signature Delivery Visit: Student provides: Articulator with maxillary and mandibular mounting casts mounted, handpiece, processed dentures 01 cassette, RDK (removable denture kit), PIP, acrylic burs, aluwax, Hanau and Lenk torches, water baths, articulating paper

Clinic provides:

Procedures to be completed: Adjust the fit of maxillary and mandibular denture bases with PIP PRECEPTOR CHECK Evaluate esthetics and phonetics Verify centric relation (with aluwax!) PRECEPTOR CHECK Always be prepared to do a clinical remount and understand how occlusal adjustments are made. Instruct patient on care and maintenance of dentures and schedule 24 hour recall

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Recall Visits: Student provides: Clinic provides: handpiece 01 cassette, PIP, acrylic burs

Procedures to be completed: Evaluate fit and comfort of denture Discuss with patient any difficulties encountered Make adjustments PRECEPTOR CHECK before adjusting and after completed Schedule of recall appointments: 24 hours, 1 week, 2 weeks, 1 month, 6 months, then yearly. The number of appointments may vary depending on the patients particular needs.

Submitting Complete Denture Cases to the Laboratory

Work Authorizations must always by filled out completely and signed by the student and the preceptor who was the last to supervise the case in the clinic. The preceptor will not sign the prescription until all steps necessary to send the case to the lab are complete.

The following specific details will be checked by faculty:

The casts must be neatly mounted on a semi-adjustable articulator at correct vertical dimension of occlusion. There are no interferences at the heels of the casts. For monoplane posterior teeth, the condylar inclination is set at 0 degrees. A "tight" interocclusal relationship is present between the maxillary and mandibular posterior teeth. The anterior teeth have no interocclusal contact. The wax contours are smooth, and the denture teeth are wax free.

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IMMEDIATE DENTURES
Immediate Denture Protocol
Please refer to Section X of the Complete Denture Prosthodontics Syllabus for a complete description of the immediate denture technique. All students must read and be familiar with this section prior to presenting with the patient for final impressions in the prosthodontic clinic.

General Guidelines:
1. Immediate dentures are to be made for the maxillary arch only. Treatment planning mandibular immediate dentures is strongly discouraged and treatment cannot be done in the student clinic. Please remember to include the cost of a reline in the original treatment plan. 2. Posterior teeth should be extracted approximately two months prior to the date of the final (anterior) extraction/immediate denture delivery appointment. 3. Final impressions for immediate dentures are to be made with alginate material in the best fitting tray possible. This could be either a partially dentate metal stock tray or a green plastic stock tray. 4. Any mandibular prosthesis (complete denture or RPD) is tried in and adjusted at an appointment other than the final extraction/immediate denture delivery appointment. The 24 hour post insertion appointment is generally an acceptable time for delivery of the mandibular prosthesis. 5. The patient must be appointed for the OMFS clinic at either 9:00 AM or 1:00 PM (2:00 PM if the 3rd year student has a 1:00 PM class) for the final extraction appointment. 6. The day of the final extractions and the delivery of the immediate denture the following must be done: a) The student must check in with Prosthodontics Clinic faculty prior to the extractions being done. Faculty will have the opportunity to evaluate the prosthesis and then the student will place the immediate denture into a disinfectant solution b) The extractions will be done in the OMFS clinic c) The patient must be moved to the Prosthodontics Clinic no later than 10:30 AM or 3:30 PM in order for the student to have adequate time to adjust and deliver the immediate denture

Rev. 12/11

RELINING DENTURES
Protocol
Please read the Complete Denture syllabus for the appropriate technique for manipulating the materials for a denture lab processed reline. This section will discuss clinical protocols on management of the patient and lab resources. Relines will be indicated in various situations and the student must be certain as to which one applies in order to enter the correct codes in QR and bill the patiently accordingly. 1. The patient requires a reline of a conventional maxillary or mandibular denture because the processed bases were found to have inadequate retention at the JRR, esthetic try-in or delivery visit. These patients are NOT charged for this reline. The denture codes in QR should be kept as incomplete until the reline has been successfully delivered. The student does not receive 1/3 arch credit for these reline procedures. 2. The patient requires a reline of an immediate denture. These patients must be billed for any relines, as the fee is not included in the cost of the denture and MUST be included as part of the initial treatment plan. The code to be used is 5750. The student will receive 1/3 arch credit for these reline procedures. 3. All other relines will likely fall under the 5750 code for dentures that have been made over one year ago by UCSDM. However, this must be evaluated by the faculty on a case-by-case basis. IMPORTANT CONSIDERATIONS FOR DENTURE RELINES ALWAYS SCHEDULE YOUR RELINES WITH THE LAB BEFORE SCHEDULING YOUR APPOINTMENTS FOR THE PATIENT! NOTE: In order for the Lynal to act as an impression for a reline, the denture must be worn for a minimum of 1 hour! The ideal time is 24 hours. The maximum is approximately one week. The condition of the Lynal will be the determining factor. The prescription reads: Please use cold cure processing with clear resin for this reline (or rebase). Thank you. (Please confirm with the preceptor that this is the correct material for the situation being addressed clinically.) The denture will be processed overnight, so the patient must plan to be without the denture for 24 hours. Delivery of a relined denture is the same as delivering a conventional denture (Section IX of syllabus.) You must adjust internally with PIP, check CR, VDO and occlusion. Recalls must also be scheduled similar to a conventional denture delivery. 25

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REMOVABLE PARTIAL DENTURES

Guidelines for Submitting Removable Partial Denture Cases to the Laboratory For metal framework fabrication:
The final impression should be made with alginate and a metal stock tray Master casts must be poured in vacuumed die stone Tuberosities and hamular notches must be included on maxillary cast for Kennedy Class I and Class II RPDs Tongue area flat and retromolar pads included on mandibular cast Trimmed "land" area 3 - 4 mm, full vestibule and adequate thickness (1/2 to 3/4") of cast Cast notched for mounting Master cast surveyed and tripoded only Detailed drawing of framework on diagnostic cast or duplicate of master cast with a red pencil Casts mounted on a semi-adjustable articulator if there is potential for occlusal interferences with rests or connectors Detailed description of each component written on lab authorization Faculty will not sign prescription until all of the above are completed

The student is expected to set the denture teeth on the framework:

In order for the student to accomplish this, faculty will look for the following: A positive, accurate and stable interocclusal record is present No interferences at heels of casts Casts mounted neatly on semi-adjustable articulator at correct vertical dimension of occlusion Record bases and framework fully seated on cast No occlusal interferences from rests or connectors Complete tooth order instructions given

Note:
The student will submit the case to the Laboratory for wax refinement and processing after all of the denture teeth are set in baseplate wax on the framework and the correct tooth position is verified by faculty. The extensions of the denture base areas must be marked on the master cast in red pencil using the same guidelines as established for flange extensions for a complete denture. Faculty must sign the prescription.

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Tips for Designing RPDs

I. Questions:
1. What teeth are to be replaced and why? 2. Will the RPD be tooth supported or tooth-tissue supported? 3. What is the condition of the potential abutment teeth (periodontal condition, caries, etc)? 4. Are there acceptable undercut areas on abutment teeth? 5. Would modification of axial/proximal contours or heights of contour improve the prognosis
of the RPD?

6. Is there sufficient occlusal clearance to accommodate occlusal rests and other components? 7. Does your clasp assembly design incorporate 180 encirclement for distal extension
situations?

8. Are there anatomic concerns (tori, excessive soft tissue, tissue undercuts, etc.) that must be
corrected or avoided with the proposed design?

9. Given the patients past disease history and current status, should the RPD be designed with
the potential for modification should teeth be lost in the future?

Note: If the student has any opportunity to fabricate an RPD at a Community Health Center Rotation, then the RPD MUST be designed at UCONN with full-time prosth faculty at open hour.

II. Guidelines for RPD framework design

1. Every component added must have a specific function (KISS principle). 2. To survey, begin with the occlusal plane parallel to the floor. 3. Select a major connector that will fit into the space available (lingual bar vs. lingual plate) and will provide support where necessary (maxillary distal extension situations). 4. Spaces narrower than 5mm between minor connectors should be plated closed. 5. Eliminate anterior modification spaces whenever possible (or whenever practical). 6. Identify the fulcrum line and then provide indirect retention for distal extension situations. 7. Rest on all teeth adjacent to edentulous spaces (exceptions: incisors or weak/mobile teeth). 8. Rest on the side adjacent to the edentulous space in tooth bound spaces.

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II. Guidelines for RPD framework design, cont

9. Rest on the side of the tooth away from distal extension spaces (exception: when occlusion or restorations dictate otherwise). 10. Mesial occlusal rests on first premolars are preferable to cingulum rests on canines. 11. When tipped mandibular molars are present, place large mesial occlusal rests on them for support, but do not clasp them under normal circumstances. 12. The horizontal retentive arm (Grasso clasp) is the standard clasp for most indications. Deviations from this general approach should be verified with a faculty preceptor. 13. Clasp only two teeth in distal extension situations (exception: some Kennedy Class II situations). 14. Avoid embrasure rests whenever possible. 15. Cast restorations for RPD abutments MUST be evaluated for occlusal rest position, shape, size and occlusal clearance as well as appropriate proximal, lingual and buccal contours prior to cementation. A note that this evaluation has taken place must be entered into the daily Progress Notes.

III. Transitional/Interim Partial Dentures

Transitional partial dentures that involve both anterior and posterior teeth are billed using the 5211 or 5212 codes in QR (maxilla and mandible respectively.) Interim partial dentures that replace only 3 to 4 teeth are billed using the 5820/5821 codes. The student must set the teeth for all transitional or interim RPDs. Students should not be fabricating flippers for patients. All work should be directed through the prosthetic laboratory, and patients must be billed accordingly. Note: State insurance will only pay for one prosthesis every 5 years. If a patient requires an interim RPD and a conventional RPD, then the patient must be informed that he/she must pay for the interim RPD out of pocket.

Rev. 12/11

Students Guide to RPDs

The typical removable partial denture patient will require a comprehensive treatment plan. This will require you to complete your data collection for all of the patients perio, endo, and operative needs. The partial denture is only one phase of the patients treatment, but it must be considered at the outset when developing the overall treatment plan. ************************************************************************ Clinical Visit: Student provides: Clinic provides: Exam, Data Collection, Alginate Impressions Bowl, spatula, red/blue pencil 01 cassette, alginate, green stock trays (adhesive), EPT, disclosing solution

Procedures to be completed: Review patients medical history (oral diagnosis faculty consult if not already completed) Review patients dental history and perform intraoral and extraoral exam completing perio, operative and endo data bases. Make alginate impressions for diagnostic casts The first appointment with the patient should be used to complete data collection. It is always a good idea to make impressions for diagnostic casts at this time. They will be invaluable for later consultations with faculty. At this stage the student should begin to consider a design for an RPD if indicated. A consultation with a pros faculty or team leader early on may save you time with data collection if many teeth are hopeless or will not be functional in the RPD. They may recommend that a facebow transfer be done at this time to later assist in mounting the diagnostic casts. ************************************************************************ Clinical Visit: Student provides: Clinic provides: Treatment Planning Trimmed and articulated diagnostic casts, completed data base 01 cassette

Procedures to be completed: Obtain consults from perio, endo, operative and prosthodontics If you have not already done so, the prosthodontic faculty will request you to have your diagnostic casts mounted for evaluation of occlusion, etc. This may require an additional clinical appointment before the RPD can be finally designed. 29

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The patient will do A LOT of waiting at the consultation appointment. It is always a good idea to have your patient bring a book to this appointment. (It also may take longer than one appointment to finish treatment planning consultations.)

************************************************************************ Clinical Visit: Mounting Diagnostic Casts (if not already done, i.e. record bases need to be made) Trimmed diagnostic casts, Triad record bases with occlusion rims, articulator and facebow, slow speed handpiece, bowl and spatula 01 cassette, RDK (removable denture kit), acrylic burs, baseplate wax, aluwax, Hanau and Lenk torches, hot water bath (set at 125 F)

Student provides:

Clinic provides:

Procedures to be completed: Facebow transfer Interocclusal record using the essentially the same techniques as taught in the complete denture course

************************************************************************ Laboratory Procedure: Designing RPD

Procedures to be completed: After you have discussed the case with one of the prosthodontic faculty and an RPD has been decided upon, a final design must be worked up. THE STUDENT MUST NEVER TAKE THE TIME TO FINALIZE A PARTIAL DENTURE DESIGN WHILE A PATIENT IS WAITING IN THE CHAIR!!!!!! Designs should be finalized with faculty during Wednesday 12-2 pm open hours in the Reconstructive Sciences conference room (L6105). Before discussing a design with a faculty member, the student must have worked up a tentative design to discuss with the faculty. When discussing the design with faculty the student will need: A surveyor The patients chart with radiographs Mounted diagnostic casts Red pencil Your tentative design on a sheet of paper When the design is completed and approved by the faculty, it must be transferred into the progress notes of the chart using the design sheet on the following page. Both the student and the faculty member must sign the design.

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************************************************************************ Clinical Visits: Complete Phase I therapy

Procedures to be completed: All perio, restorative and endo treatment must be completed and a Phase I Reevaluation must be done before any Phase II treatment (crowns, bridges, RPDs) can be started. Once the Phase I re-eval is done and the appropriate signatures are entered into the chart, mouth preparation can begin for the partial denture. All operative and crown and bridge procedures must be considered part of the mouth preparation. What you dont want to have happen is cement a crown and then have to remove it and remake it because you forgot that the crown needed rests, undercuts, etc. ************************************************************************ Clinical Visit: Student provides: Mouth Preparation and Final Impression Mounted diagnostic casts with design, high speed handpiece, bowl, spatula, vacuum mix bowl 02 cassette, general burs, metal trays, alginate

Clinic provides:

Procedures to be completed: Mouth preparation Final impression with alginate in metal tray Alginate of the opposing arch is also necessary Final impression is poured within 15 minutes in vacuum mixed die stone making certain all borders are included. (The cast(s) should be separated from the impression 45-60 minutes after pouring so the surface is not damaged by remaining in contact with the drying alginate. The cast(s) should be allowed to dry overnight before trimming, surveying, etc.) NOTE: IF composite resin cingulum rests are planned for mandibular canines, they will probably require a separate visit ************************************************************************

Rev. 12/11

Laboratory Procedures:

Submitting Case to Lab for Framework Fabrication

Procedures to be completed: The trimmed master cast is surveyed and tripoded. A laboratory prescription is written and then reviewed and signed by preceptor. The case is submitted to the laboratory including: master cast study cast with design drawn opposing cast (mounted if necessary to evaluate occlusion) signed work authorization It will take 10 working days for the framework to be returned from the lab assuming the case is not held up in Quality Control. ************************************************************************ Clinical Visit: Student provides: Framework Try-in and Jaw Relationship Records Framework on master cast, cast of opposing arch, high and slow speed handpieces, bowl, spatula, facebow, articulator, metal calipers, red pencil RDK tub, general burs, acrylic burs, disclosing materials (fit checker, PIP, etc.), pliers for adjusting clasps, torches, wax, hot water bath

Clinic provides:

Procedures to be completed: Framework is adjusted and seated. Occlusion is carefully checked to insure that the RPD framework does NOT alter the normal occlusal contacts. Record base and occlusion rims are made using baseplate wax on framework. Jaw relationship records are completed (following the procedures outlined for complete dentures) ************************************************************************ Laboratory Procedure: Set Teeth Procedures to be completed: Set teeth, wax contours should be smooth and teeth wax free Denture teeth usually will require adjustment/alteration to fit into the space available and to articulate properly with opposing natural teeth. Articulator should be clean ************************************************************************ 33

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Clinical Visit: Student provides:

Esthetic Try-In and Verification of JRR Mounted casts with teeth set on frameworks, slow speed handpiece, bowl, spatula, articulator 01 cassette, RDK (removable denture kit), acrylic burs, baseplate wax, aluwax, Hanau and Lenk torches, water baths

Clinic provides:

Procedures to be completed: Evaluation of esthetics and phonetics Evaluation of vertical dimension Verify centric relation (if mounted in CR) Verify correct occlusion An esthetic try-in may not be necessary if no anterior teeth are being replaced and there are no doubts about the accuracy of the jaw relationship records. Check with your preceptor. ************************************************************************ Laboratory Procedure: Finalize Wax Up to Submit to Lab for Processing of Teeth Procedures to be completed: The case is ready to submit to the lab when: Appropriate occlusion developed specific to case Articulator clean Wax contours smooth Final extensions of denture flanges marked in red pencil on cast and/or wax extended to appropriate coverage Teeth wax free Work authorization to laboratory: Please beautify wax up Process, finish and polish Thank you Preceptor signature

************************************************************************

Rev. 12/11

Clinical Visit: Student provides:

Delivery High and slow speed handpieces, red pencil, metal calipers, processed partial dentures 01 cassette, RDK (removable denture kit), PIP, acrylic burs, aluwax, Hanau and Lenk torches, water baths, articulating paper, pliers for adjusting clasps

Clinic provides:

Procedures to be completed: Adjust the fit the partial dentures (you may need to adjust the metal as well as the acrylicideally it should only be acrylic!) Verify occlusion Evaluate esthetics and phonetics Instruct patient on care and maintenance of partial dentures Schedule recall for 24 hours ************************************************************************ Clinical Visit: Recalls Student provides: Clinic provides: Handpieces 01 cassette, PIP, acrylic burs, articulating paper

Procedures to be completed: Evaluate fit and comfort of partial denture Discuss with patient any difficulties encountered Make adjustments PRECEPTOR CHECK before adjusting and after completed ************************************************************************ PLEASE UNDERSTAND THIS IS ONLY A ROUGH GUIDE. EACH PATIENT WILL BE DIFFERENT AND MAY REQUIRE SIGNIFICANT MODIFICATIONS FROM THE SEQUENCE AND/OR PROCEDURES DESCRIBED ABOVE. THIS SHOULD SERVE AS A GENERAL REFERENCE ONLY WITH YOU FILLING IN THE DETAILS WITH INFORMATION GATHERED FROM LECTURES, READING AND ASKING QUESTIONS!

NOTE: All removable prosthesis deliveries require recall appointments. This includes relines and transitional partial dentures. Credit for any removable prosthesis is not granted until the student has completed the one month recall with the patient.
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IMPLANTS
UCONN Undergraduate Single Tooth Implant Protocol
The single tooth implant protocol allows each dental student to offer single tooth implant restorations to their patients and 2 implants for an overdenture patient.

I. General Treatment Planning Information:

Consultation with prosthodontic faculty must be the first step before committing to treatment. This is required! Consultation should be with Drs. Dhingra, Duncan, Nazarova, Patch or Taylor only. Diagnostic casts and appropriate radiographs are okay for consult with above faculty. The orange treatment planning sheet will be REQUIRED with requisite signatures (see checklist below). Only single tooth replacement is available. Posterior teeth only (premolars and 1st molars) Adjacent implants may not be done in the predoctoral clinics. Patients requiring side-by-side implants must be referred to either graduate prosthodontics or AEGD for treatment planning this area. Only sites that do not require augmentation (grafting) prior to implant placement are acceptable.

See the most current fee schedule for procedure costs. The fee includes the cost of
the implant, abutment, crown and surgical guide. It does not cover the cost of preoperative radiographs.

The code is 16013 in procedure group 61. The procedure conveniences must be
included. The restoration will be a cemented crown on a standard solid abutment, no angled are to be used in the student clinics. The implant will either be a standard solid regular or wide neck implant. No narrow neck implants will be used on student cases. Patients who are offered this treatment must have a good track record (i.e., reliable, prompt, compliant, etc.) Patients who smoke are not eligible.

Rev. 12/11

Patients for whom elective surgical procedures are contraindicated are not appropriate candidates for this treatment option. (e.g., uncontrolled diabetics, chronic systemic steroid use, immune-compromised, etc.) Patients must be made fully aware that if, at the time of surgery, it is discovered that a graft is needed to place the implant or anything other than a standard abutment will be required to restore the implant, then the patient will become a residents patient and must pay resident fees. The patient must sign the Student Implant Program Consent Form which is attached to the orange checklist sheet. Students may work with either Oral Surgery or Perio for implant placement.

II. Pre-operative Sequencing: Prosthodontic consultation is done during treatment planning. Faculty approval of implant treatment must be obtained at this stage. Consultation with PROSTHODONTIC FACULTY must be the FIRST step before committing to treatment. This is required!
The student obtains a surgical consult from Periodontal or Oral Surgery FACULTYnot a resident. Reminder: this only occurs AFTER a prosthodontic consult. Surgery consults should NOT be obtained from a resident in either discipline. Patient surgical consultation may be obtained at same clinic session as prosthodontic consultation or at a subsequent visit. The informed consent reviewed and signed. Additional radiographs (panorex, etc.) deemed necessary should be ordered at this time. A surgical guide is fabricated by the student and must be approved by prosthodontic faculty and surgeon. The fee is collected prior to the surgery appointment.

III. Surgery:
During surgery the student assists the resident/faculty in placement of the implant. Peri-operative antibiotic medication and post-operative pain medication will be given as directed by the resident/faculty involved with surgery.

The implant should not be signed off in QR as complete at this time! Only the implant placement is complete--please note the appropriate
procedure conveniences. 37

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Patients must be made fully aware that if, at the time of surgery, it is discovered that a graft is needed to place the implant or anything other than a standard abutment will be required to restore the implant, then the patient will become a residents patient and must pay resident fees.

IV. Post-Operative Period:

The student should contact the patient by telephone 24 hours post-placement to verify that the patient is comfortable. The patient is seen for follow up 1 week after implant placement. A minimum of 6 weeks post-surgery is necessary for healing/osseointegration.

V. Restorative Procedure:
A solid abutment is selected and inserted into the implant. A final impression is made. The implant/abutment must be covered either with a protective cap or with a provisional crown. The final restoration is cemented with zinc phosphate cement.

VI. Follow-up/Recall:
6 month recall. Annual recall. Periapical radiographs should be taken at the 1 year recall and then every 3 years unless there is concern about the health/stability of the implants

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VII. Additional Logistic Information:

The following will answer some of the logistical questions regarding implants in the student clinics: 1. Procedure codes: The code to be used for the predoctoral implant (see most current fee schedule for cost) is found under the heading of "other implant services." The single implant crown code is 16013. Procedure conveniences MUST BE INCLUDED!! The procedure conveniences will cover the implant placement, abutment connection, impression and crown delivery for code 16013. The appropriate steps are covered for the overdenture code. The implant should not be entered as complete until the crown is delivered! 2. Abutment connection: Abutments should be connected in Clinic 4. The Straumann kits have the appropriate instrumentation for either the overdenture or implant crown. 3. Clinic and lab implant components: The components that are needed to restore single implant crowns (abutments, impression copings, protective caps, lab analogs, etc.) and implant overdentures are available at central support. 4. Treatment planning: Be sure to follow the protocol above. A few important reminders and updates:

Patients who require grafts, sinus lifts, immediate placement, etc will not be eligible for the student program. Only straightforward, uncomplicated and ideal sites should be considered. Only posterior teeth may be replaced: premolars and 1st molars. Patients must be made fully aware that if, at the time of surgery, it is discovered that a graft is needed to place the implant or anything other than a standard abutment will be required to restore the implant, then the patient will become a residents patient and must pay resident fees.

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MANDATORY CHECKLIST FOR STUDENT IMPLANT PROGRAM

Patient Name: TOO #:

Consult with Prosth Faculty FIRST STEP OF DATA COLLECTION Student must have mounted diagnostic casts and radiographs Date: *Faculty Signature: Comments: Consult with Surgical Faculty (Resident Consults are Unacceptable)- Data Collection Assessment of Alveolar Bone Volume - by Surgical Faculty (Perio/OSurg) Can be by radiograph, sounding, clinical exam Consent signed Date: **Faculty Signature: Comments: Surgical guide approved by prosthodontic faculty *Signature: Date:

Consult with Surgical Faculty - Final Review Must Be At Least 3 Months Post Extraction Must Review Surgical Guide **Faculty Signature: Date:

Fee collected for procedure prior to implant placement! *Acceptable Prosth Faculty Signatures: Drs. Dhingra, Duncan, Nazarova, Patch, or Taylor ** Acceptable Surgery Faculty Signatures: OSURG Goupil, Landesberg, Piecuch, Shafer, Song PERIOAlmas, Cantner, Diaz, Dongari, Ioannidou, LaPorta, Nichols, Schincaglia

Rev. 12/11

UCONN Undergraduate Implant Overdenture Protocol

The protocol is very straightforward and provides every student the opportunity to offer dental implant anchorage to one patient for whom s/he has already fabricated a mandibular complete denture. The student assists a resident or faculty member with the placement of the first implant and then places the second implant assisted by the resident or faculty member. The implants are placed anterior to the mental foramina in the lateral incisor position. Following implant placement the patient avoids use of the denture for a week to 10 days and the student then relieves the denture and places a soft temporary liner to allow its use during the remainder of the healing period. The protocol recommends a six-week healing period prior to loading the implants. At the six-week stage the student places ball anchor attachments into the implants and the denture is permanently relined incorporating the retentive matrices in the base of the denture. With no cost components and instrumentation from the company, the entire process of implant placement and restoration is minimal and well within the financial capability of most of our denture patients. Please refer to most current fee schedule for precise cost which includes the surgical and restorative phases unless the patient requests sedation during surgery. In that case an additional fee will be charged to the patient.

I. General Treatment Planning Information

Under NO circumstances should implants be mentioned in the treatment planning of a patient for complete dentures. Only after successful delivery of new dentures should you discuss the possibility of implant anchorage for the mandibular denture. The student should not and cannot promise implants before the dentures are made because it is possible that your patient may not be an implant candidate for any number of reasons. Refer to the fee schedule for the current fee for the student complete implant procedure. This fee includes the implants, surgical guide, surgery, prosthodontic components and reline. Any radiography performed or sedation during surgery will require additional cost to the patient and/or their insurance carrier. The implant treatment option is available only for patients with new dentures that were fabricated in our clinics. Patients who are offered this treatment must have a good track record (i.e., reliable, prompt, compliant, etc.) Patients who smoke are not eligible.

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Patients for whom elective surgical procedures are contraindicated are not appropriate candidates for this treatment option. (e.g., uncontrolled diabetics, chronic systemic steroid use, immune-compromised, etc.) Consultation with prosthodontic faculty must be the first step before committing to treatment. This is required! Consultation should be with Drs. Dhingra, Duncan, Patch, Nazarova or Taylor only. Diagnostic casts and appropriate radiographs are okay for consult with above faculty. Treatment planning sheet will be REQUIRED with requisite signatures (see checklist below). Surgical guide must be approved by prosthodontic faculty (not surgeon!). Students may work with either Oral Surgery or Perio for implant placement.

II. Pre-operative Sequencing

Prosthodontic consultation is done during treatment planning. Faculty approval of implant treatment must be obtained at this stage. Consultation with prosthodontic faculty must be the first step before committing to treatment. This is required! The student obtains a surgical consult from Periodontal or Oral Surgery FACULTY. Reminder: this only occurs AFTER a prosthodontic consult. Surgery consults should NOT be obtained from a resident in either discipline. Patient surgical consultation may be obtained at same clinic session as prosthodontic consultation or at a subsequent visit. The informed consent reviewed and signed. Additional radiographs (panorex, etc.) deemed necessary should be ordered at this time. The fee is collected prior to any further procedures commencing. Surgical guides are mandatory for implant placement. The mandibular denture is duplicated in clear acrylic resin by the student. Help/supervision of this procedure can be obtained in the dental lab. The surgical sites will be marked on the duplicate denture (surgical guide) and holes (5 mm in diameter) will be drilled through the surgical guide. Surgical guide must be approved by prosthodontic faculty (not surgeon!). The patient must be made aware that the implant procedure will require that they be without the mandibular denture for 7-10 days following surgery and for 2 days following the reline appointment.

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III. Surgery
During surgery the student assists the resident/faculty in placement of the first implant and then the student places the second assisted by the resident/faculty. Peri-operative antibiotic medication and post-operative pain medication will be given as directed by the resident/faculty involved with surgery.

IV. Post-Operative Period

One week to 10 days following surgery the denture is relieved over the implant sites and soft liner is placed. A minimum of 6 weeks post-surgery is necessary for healing/osseointegration.

V. Reline Procedure
The abutments, abutment analogs, and retentive matrices are obtained from the staff in the Reconstructive Sciences office (L-6078). The initial checklist must be handed presented at this time to receive the components and required patient information must be entered in the implant log. During the reline appointment the soft, temporary reline material is completely removed from the denture. The cover screws are removed from the implants, the implants irrigated, and the ball anchor abutments placed into the implants with finger tightening. Faculty evaluation of the height of the abutments must be obtained prior to torque tightening the abutments. When deemed acceptable the abutments are tightened to 35 Ncm. Periapical radiographs should be made at this appointment and will serve as the baseline record of peri-implant bone levels. A reline impression is made in the denture using medium body polyvinylsiloxane (Reprosil). The reline should be done with a closed mouth technique to maintain correct occlusal contact with the upper denture. There must be no contact between the ball anchor and the denture base. If show-through to the denture is seen, the denture should be relieved further and the reline impression redone. The analogs are inserted into the impression and a cast is carefully poured in yellow stone with the assistance of staff in the dental lab or faculty. The lab will process the reline over a 24 hour period (The student must provide the retentive matrices to the lab for processing). 43

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The relined denture should be checked with PIP and the retentiveness of the matrices should be evaluated. If the patient is not able to easily place and remove the denture the matrices should be adjusted to decrease the retention.

VI. Follow-up/Recall
The student should contact the patient by telephone within 24 hours of delivery to verify that the patient is comfortable. One week recall visit to evaluate tissue health and patient comfort/satisfaction. 6 month recall. Annual recall. If any calculus is present on the implant components, use only a plastic scaler (available in each clinic). Periapical radiographs should be taken at the 1 year recall and then every 3 years unless there is concern about the health/stability of the implants.

VII. Additional Logistical Information:

1. Procedure codes: The code to be used for the predoctoral overdenture is found under the heading of "other implant services." The overdenture code is 16014. Procedure conveniences MUST BE INCLUDED!! The procedure conveniences will cover the implant placement, abutment connection, impression and reline for code 16014.

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PROGRESS EVALUATIONS
PROGRESS EVALUATIONS SUMMARY: 3RD YEAR TYPODONT PROGRESS EVALUATION BRIDGE 19-20 WITH PROVISIONAL 4TH YEAR TYPODONT PROGRESS EVALUATION BRIDGE 6-8 WITH PROVISIONAL TREATMENT OUTCOMES ASSESSMENT PROGRESS EVALUATION REMOVABLE PROSTHODONTICS OSCE-TYPE PROGRESS EVALUATION CLINICAL PROSTHODONTIC PROGRAM PROGRESS EVALUATION

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I. Typodont Progress Evaluations (PE)

1. The 3 year PE and 4 year PE require bridge preparations and provisionals. The 3 year
rd th rd

PE involves teeth 19 through 21, and the 4th year PE involves teeth 6 through 8.
2. The 3 year PE forms are green, and the 4 year forms are blue. You have 6 hours from
rd th

start to finish. You are on the honor code to track the time used.
3. Appropriately designated typodont teeth (colored) will be signed out from the dispensary.

Only these teeth will be considered for grading as a PE.

4. The student should bring the typodont to the Division Office (L6078) for grading. 5. Grading occurs on Wednesdays during Open Hours when multiple faculty are available.

Please keep this in mind when deadlines are approaching. accommodations will not be made, please plan accordingly. this page.

Special grading

6. Only self-evaluated sheets will be graded. Grading is done using the criteria that follow 7. You may bring in a putty matrix or vacu-form matrix with you. This is not included in the

6 hours. You may make your provisional with an indirect technique, but this must be done within the 6 hours and in the appropriately designated working environment.
8. You may make a diagnostic cast of your preparations to evaluate them, but you may not

confer with anyone regarding this cast. This work must be included in the 6 hours allotted to work on the PE.
9. Work should be completed on the mannequin stand with the shroud. (Similar to NERBs) 10. You may not solicit feedback on any stage of the PE from any source. All work is to be

completed independently. Any deviation from this will be considered an honor code violation.
11. If the 3rd year competency is passed by the 3rd year March APC meeting, you will receive

one unit of fixed to count toward your total experience. If the 4th year competency is passed by the 4th year December APC meeting, you will receive one unit of fixed to count toward your total experience. The 4th year progress evaluation may be challenged during the 3rd year.
12. You may abort the PE at anytime if you feel that it will not pass. This is part of your

ability to self-evaluate. You MUST, however, return the teeth that you started working on in order to receive a new set of teeth. Having multiple sets of teeth out will be considered an Honor Code violation.
13. The typodont teeth for passed progress evaluations will be removed from the typodont and

kept by the Division.

Rev. 12/11

Evaluation criteria for full cast crown preparation for tooth #19
Finish line & Walls Smooth walls Smooth, continuous and welldefined margins Angle of convergence of 6-10o External outline Internal outline Light chamfer on buccal and lingual continues to proximal 0.5-1.0 mm coronal to CEJ Buccal: 0.8-1.0 mm axial reduction in two planes; Lingual: 0.8 to 1.0 mm reduction Rounded line and point angles Functional cusp: 1.5 mm Nonfunctional cusp: 1.0 mm Maintains general occlusal anatomy Slight roughness of walls Slight roughness of margins Slightly discontinuous margins Slight lack of definition Under tapered (0-5o) or over tapered (>10o) More than 1.0 mm coronal to CEJ or less than 0.5mm coronal to CEJ Inappropriate size of margin for 1 location Buccal and lingual: slightly over (>1.0mm) or under (<0.8mm) Slight lack of rounded line or point angles Functional cusp: slightly over (>1.5 mm) or under (1.0 mm) reduced Non-functional cusp: Slightly over reduced (1.0-1.5 mm) or under reduced (>0.5 but <1.0 mm) Presence of shoulder margin More than 1.5 mm coronal to CEJ or at the level of gingival margin Buccal and lingual: moderately over( 2.0 mm) or under (<0.5 mm) reduced Moderate lack of rounded line or point angles Functional cusp: moderately over reduced (2.0-2.5 mm) Non-functional cusp: moderately over reduced (1.52.0 mm) Inappropriate size for 2 or more locations or presence of butt-joint margin at proximal or lingual surface Buccal and lingual: severely over (>2.0mm) or under reduced (<0.3 mm) or no two-plane buccal reduction Severe lack of rounded line or point angles Functional cusp: reduction 2.5 mm or <1mm Non-functional cusp: reduction 2.0mm or 0.5 mm Wrong tooth prepared Slight damage to adjacent tooth Moderate damage of gingival shroud No damage to adjacent tooth Treatment management No damage to gingival shroud

II

Slight damage to gingival shroud

Poorly defined and moderate roughness of walls Moderate roughness of margins or margins are non-continuous Over tapered (>16o)

III

Unfinished and severe roughness of walls Severe roughness of margins or unsupported enamel remaining IV Undercut between any set of opposing axial surfaces or line angles

Severe damage to gingival shroud Moderate to severe damage to adjacent tooth

Finish lines are subgingival

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Evaluation criteria for full cast crown preparation for tooth #21
Finish line & Walls External outline Internal outline 1.0-1.2mm Shoulder with internal rounded line angle on the buccal and gradually diminishing from mesial and distal to 0.5 mm chamfer on lingual 0.5-1.0 mm coronal to CEJ Buccal: 1.0 - 1.5 mm axial reduction in two planes Lingual: 0.8 to 1.0 mm reduction Rounded line and point angles Angle of convergence of 6-10o Functional cusp: 1.5-2.0 mm Non-functional cusp: 1-1.5mm Maintains general occlusal anatomy Inappropriate size of margin for 1 location No damage to adjacent tooth Treatment management No damage to gingival shroud

Smooth walls Smooth, continuous and well-defined margins

Slight roughness of walls Slight roughness of margins Slightly discontinuous margins Slight lack of margin definition

II

More than 1.0 mm coronal to CEJ or less than 0.5mm coronal to CEJ

Buccal: slightly over (>1.5mm) or under (<1.0mm) Lingual: slightly over (1.0mm) or under (<0.8mm) Slight lack of rounded line or point angles Functional cusp: slightly over (2.0-2.5mm) or under (1.0-1.5 mm) reduced Non-functional cusp: Slightly over reduced (1.52.0 mm) or under reduced (0.5-1.0 mm) Presence of chamfer on the buccal or undermined enamel at any location

Slight damage to gingival shroud

Under taper (0-5o) or over taper (>10o)

Poorly defined and moderate roughness of walls Moderate roughness of margins or margins are non-continuous Over taper (>16o) More than 1.5 mm coronal to CEJ Or at the level of gingival margin

Moderate damage of gingival shroud

III

Buccal: moderately over(>2.0 mm) reduced Lingual: moderately over (1.5 mm) reduced Moderate lack of rounded line or point angles Functional cusp: moderately over reduced (2.53.0 mm) Non-functional cusp: moderately over reduced (2.0-2.5mm) Inappropriate size for 2 or more locations or presence of shoulder margin at lingual surface Buccal: severely over (>3.0mm) or under (<0.5mm) reduced or no two-plane buccal reduction Lingual: severely over (>1.5 mm) or under (0.5 mm) reduced Severe lack of rounded line or point angles Functional cusp: reduction > 3.0 mm or < 1.0 mm Non-functional cusp: reduction>2.5mm or <0.5 mm Wrong tooth prepared Slight damage to adjacent tooth

Unfinished and severe roughness of walls Severe roughness of margins or unsupported enamel remaining

Severe damage to gingival shroud Moderate to severe damage to adjacent tooth

IV

Finish lines are subgingival

Undercut between any set of opposing axial surfaces or line angles

Rev. 12/11

Evaluation criteria for provisional fixed partial denture acrylic restoration (3 unit #19-21)
Line of Withdraw Margin Integrity & Surface Finish Facial/Lingual/Interproximal Contours & Proximal Contacts & Pontic Design Anatomy & Occlusion Treatment Management

Abutments have the appropriate line of draw for the FPD acrylic restoration

All marginal areas are well adapted to the tooth w/o horizontal or vertical extensions The surface of the restoration is smooth and with a minimum of voids The internal form conforms to the shape of the abutment and provides resistance and retention Vertical or horizontal overextension or short margin at 1 location (and less than 0.5mm x 0.5mm on either #19 or 21) and all marginal areas are well adapted to the teeth The surface of the restoration is smooth with a minimum number of voids The internal form, due to adjustment, deviates slightly from the shape of the abutment but still provides resistance and retention Vertical or horizontal overextension or short margin at 2 locations (and less than 1.0 mm x 1.0mm on either #19 or 21) and all marginal areas well adapted to the teeth The surface of the restoration exhibits significant irregularities including voids, pits, or porosities. The internal form, due to adjustment, deviates significant from the shape of the abutment and compromises resistance and retention form

The contours are harmonious with adjacent teeth forming proper embrasures and conducive for gingival health Good interproximal contacts as determined by thin articulating foil (shimstock) Pontic: Spheroid (convex mesio-distal and buccolingual tissue side contour) and clears the height of the residual ridge by at least 1 mm. The contours of provisional restoration deviates slightly from the normal contour of the abutment teeth or pontic tooth Slightly over or under contoured (<1mm) and/or slightly lacking of proper embrasures Pontic: Spheroid (convex mesio-distal and buccolingual tissue side contour) and clear the height of the residual ridge >1 mm but no more than 3 mm The contours of provisional restoration deviates significantly from the normal contour of the abutment teeth or pontic tooth Lack of interproximal contact as determined by thin articulating foil but not by eye

Provisional restoration reproduces normal occlusal anatomy of the abutment teeth and pontic tooth. Connector is in correct position and of proper size both buccolingually and occlusocervically Occlusal contact is present for both restoration and other teeth (which had contact prior to the restoration placement) as determined by thin articulating foil No damage or slight damage to gingival shroud

Provisional restoration reproduces normal occlusal anatomy of the abutment teeth and pontic tooth with only slightly deviation Moderate damage to gingival shroud

II

There is a slight variance to the line of withdraw

Connector is incorrectly positioned (<1mm out of position) and of slightly improper dimensions Occlusal contact on restoration prevents other teeth from contacting as determined by thin articulating paper or restoration lacks any occlusal contact as determined by thin articulating paper

III

There is significant variance to the line of draw which requires adjustment to either the retainers or the abutments to seat the restoration

Provisional restoration deviates significantly from normal occlusal anatomy

Connector is incorrectly positioned (>1mm out of position) and has significantly improper dimensions Occlusal contact on restoration prevents other teeth from contacting as determined by thin articulating foil or restoration lacks any occlusal contact as determined by thin articulating foil

Severe damage to gingival shroud

Pontic has a flat tissue surface contour

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Evaluation criteria for provisional fixed partial denture acrylic restoration (3 unit #19-21), cont.
Generalized absence of marginal adaptation and/or generalized vertical or horizontal overextension or short margin The surface of the restoration is rough and/or porous or the restoration is fractured The internal form grossly deviates from the shape of the abutment of there is total lack of retention and resistance The contours of provisional restoration do not resemble the normal contours of the abutment teeth or pontic tooth Lack of interproximal contact as determined by eye or excessive interproximal contacts and cause the adjacent tooth/teeth moved Pontic has a concave tissue surface contour and/or has no interproximal embrasures

Provisional restoration does not resemble the normal anatomy of the abutment teeth or pontic tooth

IV

The line of draw for the FPD restoration is decidedly at variance

Connector is incorrectly positioned (>2 mm out of position) and has severely improper dimensions Occlusal contact on restoration prevents other teeth from contacting as determined by eye or restoration lacks any occlusal contact as visible by eye There is premature contact in excursive movement

Wrong tooth or teeth is/are replaced in any location of the typodont. Tooth or teeth is/are misplaced in M-D and B-L orientation.

Rev. 12/11

Evaluation criteria for prepared porcelain fused to metal abutment # 6 for FPD 6-7p-8
Finish lines &Walls External outline Internal outline Facial shoulder with internal round line angles; width uniform and adequate for restoration design (1.0-1.2 mm); extending to just past mesial and distal line angles and gradually diminishing to 0.5 mm chamfer on lingual The cervical finish line is placed 0 - < 0.5 mm coronal to the crest of gingival shroud Sufficient tooth structure removed (including labial, lingual) for metal-ceramic restoration with two plane reduction on the labial Rounded line and point angles Maintains canine contour after prepared Incisal reduction: 1.5-2 mm Sufficient interocclusal distance (1-1.5 mm) for metal ceramic restoration with porcelain occlusal contacts Slight roughness of walls and/or margins Finish line is slightly irregular II Under taper (0-5o) or over taper in range of 1016o Margin width varies slightly, but is adequate for restoration design Axial walls slightly under-reduced or slightly overreduced Slight lack of rounded line or point angles Slight lack of canine contour after preparation Incisal reduction: 1-1.5 mm or 2-2.5 mm Interocclusal distance: Slightly under-reduced or slightly over-reduced Shoulder margin width exists and varies significantly in width but not more than 1.5 mm or less than 0.7 mm The cervical finish line is placed 1.0-1.5 mm coronal to the crest of gingival shroud The axial walls are significantly under-reduced or significantly over-reduced Moderate lack of rounded line or point angles Moderate lack of canine contour after prepared Incisal reduction and interocclusal distance: significantly under-reduced or significantly over-reduced Unfinished and severe roughness of walls and/or margins Finish line is unacceptable and/or having unsupported enamel remaining IV Undercut between any set of opposing axial surfaces or line angles or decidedly excessive taper The cervical finish line is placed subgingival to the crest of gingival shroud by 0.5mm or more The cervical finish line is placed more than 1.5 mm coronal to the crest of gingival shroud Facial shoulder width: 1.5mm or more in width or facial shoulder not present The axial walls are severely under-reduced or overreduced No two plane reduction of the labial wall Severe damage to gingival shroud Moderate to severe damage to adjacent tooth No damage to adjacent tooth Treatment management No damage to gingival shroud

Smooth walls

Smooth, continuous and well-defined margins Angle of convergence of 6-10o

The cervical finish line is placed 0.5- < 1.0 mm coronal to the crest of gingival shroud The cervical finish line is placed subgingival to the crest of gingival shroud but not more than 0.5 mm

Slight damage to gingival shroud Slight damage the adjacent tooth/teeth but polishing at the proximal surface was done Moderate damage of gingival shroud

Moderately rough walls and/or margins Finish line is noncontinuous or significantly irregular Over taper (>16o) but less than 20o

III

Slight damage to adjacent tooth

Severe lack of rounded line or point angles Loss of canine contour after prepared Incisal reduction: more than 3 mm or less than 1 mm Interocclusal distance: Severely under-reduced or severely over-reduced.

Wrong tooth prepared

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Evaluation criteria for prepared porcelain fused to metal abutment # 8 for FPD 6-7p-8
Finish line & Walls External outline Internal outline Facial shoulder with internal round line angle width uniform and adequate for restoration design,(1.0-1.2 mm) extending to mesial and distal and gradually diminishing to 0.5 mm chamfer on lingual The cervical finish line is placed 0- < 0.5 mm coronal to the crest of gingival shroud Sufficient tooth structure removal (including labial, lingual) for metal-ceramic restoration with two plane reduction on the labial Rounded line and point angles Incisal reduction : 1.5-2 mm Sufficient interocclusal distance (1-1.5 mm) for metal ceramic restoration with porcelain occlusal contacts Slight roughness of walls and/or margins Finish line is slightly irregular II Under taper (0-5o) or over taper in range of 10-16o The cervical finish line is placed 0.5<1.0 mm coronal to the crest of gingival shroud The cervical finish line is placed subgingival to the crest of gingival shroud but not more than 0.5 mm No damage to adjacent tooth Treatment management No damage to gingival shroud

Smooth walls Smooth, continuous and well defined margins Angle of convergence of 6-10o

Margin width varies slightly, but is adequate for restoration design Axial walls are slightly under-reduced or slightly over-reduced

Slight damage to gingival shroud Slight damage the adjacent tooth/teeth but polishing at the proximal surface was done

Slight lack of rounded line or point angles Incisal reduction: 1-1.5 mm or 2-2.5 mm Interocclusal distance : Slightly under-reduced or slightly overreduced Shoulder margin width exists and varies significantly in width but not more than 1.5 mm or less than 0.7 mm

Moderately rough walls and/or margins Finish line is noncontinuous or significantly irregular Over taper (>16o) but less than 20o

Moderate damage of gingival shroud

III

The cervical finish line is placed 1.0-1.5 mm coronal to the crest of gingival shroud

The axial walls are significantly under-reduced or significantly over-reduced Moderate lack of rounded line or point angles Incisal reduction and Interocclusal distance : Significantly under-reduced or significantly over-reduced Slight damage to adjacent tooth

Unfinished and severe roughness of walls and/or margins Finish line is unacceptable and/or having unsupported enamel remaining Undercut between any set of opposing axial surfaces or line angles or decidedly excessive taper

IV

The cervical finish line is placed subgingival to the crest of gingival shroud 0.5mm or more The cervical finish line is placed more than 1.5 mm coronal to the crest of gingival shroud

Facial shoulder width: 1.5mm or more in width or facial shoulder not present.

Severe damage to gingival shroud Moderate to severe damage to adjacent tooth

The axial walls are severely under-reduced or over-reduced No two plane reduction on the labial axial wall

Severe lack of rounded line or point angles

Wrong tooth prepared

Incisal reduction: more than 3 mm or less than 1mm Interocclusal distance: Severely under- or over-reduced.

Rev. 12/11

Evaluation criteria for provisional fixed partial denture acrylic restoration (6-7p-8)
Line of withdraw Margin integrity & surface finish Facial/Lingual/Interproximal Contours & Proximal contacts&Pontic Design Anatomy & Occlusion Treatment management

Abutments have the appropriate line of draw for the FPD acrylic restoration

All marginal areas well adapted to the tooth w/o horizontal or vertical extensions The surface of the restoration is smooth with a minimum of voids The internal form conforms to the shape of the abutment and provides resistance and retention Vertical or horizontal overextension or short margin at 1 location and less than 0.5 mm x 0.5 mm (either #6 or 8) and all marginal areas well adapted to the teeth The surface of the restoration is smooth with a minimum number of voids The internal form, due to adjustment, deviates slightly from the shape of the abutment but still provides resistance and retention Vertical or horizontal overextension or short margin at 2 location and less than 1.0 mm x 1.0 mm (either #6 or 8) and all marginal areas well adapted to the teeth The surface of the restoration exhibits significant irregularities including voids, pits, or porosities The internal form, due to adjustment, deviates significant from the shape of the abutment and compromises resistance and retention form.

The contours are harmonious with adjacent teeth forming proper embrasures and conductive for gingival health Good interproximal contacts as determined by thin articulating foil (shimstock)

Provisional restorations reproduce normal occlusal anatomy of the abutment teeth and pontic tooth. Connector is in correct position and of proper size both labiaolingually and incisocervically Occlusal contact present for both restoration and other teeth (which had contact prior to the restoration placement) as determined by thin articulating foil Provisional restorations reproduce normal occlusal anatomy of the abutment teeth and pontic tooth with only slightly deviation Connector is incorrectly positioned (<1mm out of position) and of slight improper dimensions Occlusal contact on restoration prevents other teeth from contacting as determined by thin articulating foil or restoration lacks any occlusal contact as determined by thin articulating foil

No damage or slight damage to gingival shroud No acrylic resin residue or dust left in gingival sulcus and/or on typodont

Pontic: Modified ridge lap or ovate pontic without any concave area under pontic.

The contours of provisional restorations deviate slightly from the normal contour of the abutment teeth or pontic tooth

II

There is a slight variance to the line of withdraw

Slightly over or under contoured (<1mm) and/or slightly lacking of proper embrasures

Moderate damage to gingival shroud Minimal acrylic resin residue or dust left on typodont

Pontic: Modified ridge lap or ovate pontic with slightly deviation in shape

III

There is significant variance to the line of draw which requires adjustment to either the retainers or the abutments to seat the restoration

The contours of provisional restorations deviate significantly from the normal contour of the abutment teeth or pontic tooth.

Provisional restorations deviate significantly from normal occlusal anatomy

Severe damage to gingival shroud Moderate amount acrylic resin residual or dust left on typodont

Lack of interproximal contact as determined by thin articulating foil but not by eye.

Connector is incorrectly positioned (>1mm out of position) and of significantly improper dimensions

Pontic has a flat tissue surface contour

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Evaluation criteria for provisional fixed partial denture acrylic restoration (6-7p-8), cont.
Generalized absence of marginal adaptation and/or generalized vertical or horizontal overextension or short margins The surface of the restoration is rough and/or porous or the restoration is fractured The internal form grossly deviates from the shape of the abutment and there is total lack of retention and resistance.

The contours of provisional restorations do not resemble the normal contours of the abutment teeth or pontic tooth Lack of interproximal contact as determined by eye or excessive interproximal contacts which cause the adjacent tooth/teeth to move

Provisional restorations do not resemble the normal anatomy of the abutment teeth or pontic tooth. Connector is incorrectly positioned (>2 mm out of position) and of severely improper dimensions Occlusal contact on restoration prevents other teeth from contacting as determined by eye or restoration lacks any occlusal contact as visible by eye There is premature contact in excursive movement

IV

The line of draw for the FPD restoration is decidedly at variance

Wrong tooth or teeth is/are replaced in any location of typodont Tooth or teeth is/are misplaced in M-D and B-L orientation Significant amount of acrylic resin residue or dust left on typodont

Pontic has a concave tissue surface contour and/or has no interproximal embrasures.

Rev. 12/11

3RD YEAR TYPODONT PROGRESS EVALUATION

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4th YEAR TYPODONT PROGRESS EVALUATION

Rev. 12/11

II. Treatment Outcomes Assessment (TOA) Progress Evaluation 1. Two TOA progress evaluations must be completed by graduation. 2. They are to be completed on patients for whom you have completed Phase II treatment and are ready for placement on a recall program (either OHM or denture recall). 3. The progress evaluation may be challenged during 3rd or 4th year. They do NOT need to be completed prior to NERBs as stated on the form.

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III. Removable Prosthodontics OSCE-type Progress Evaluation

The student will challenge an online comprehensive clinical OSCE-type exam focusing on all aspects of complete and removable partial denture prosthodontics. The student must pass with a minimum of 70%. a. Prerequisite: Completion of a complete denture and a removable partial denture. b. Remediation: If remediation should be necessary, the student may challenge the exam an additional time without additional patient treatment. If any additional remediation is required, the student may be required to complete another set of prerequisite patients. Challenging PE: When the student is prepared to challenge the PE, then he/she must notify Dr. Duncan via email. The PE will be offered once a month. The time and location will be verified by Dr. Duncan once she confirms the students eligibility to challenge the PE. The following outline provides the student with a guide to prepare for the Removable Prosthodontics Progress Evaluation. The course manuals and lectures posted on Blackboard from the Complete Denture and RPD courses should be used for reference. The progress evaluation will assess the student with clinically based questions from the objectives listed below.
Learning Objectives I. Complete Denture Prosthodontics A. Denture Bearing Tissues: 1. 2. Recognize normal, healthy denture bearing tissues. Distinguish between favorable and unfavorable edentulous ridge contours, arch shapes and other anatomic supporting structures for denture wear. Identify common pathologic conditions commonly associated with denture wear. a. Inflammatory papillary hyperplasia b. Epulis fissuratum c. Angular cheilitis d. Combination syndrome Identify non-pathologic conditions of the hard and soft tissues that will require surgical intervention.

3.

4.

Rev. 12/11

B.

Complete Denture Impressions 1. 2. 3. Describe the appropriate techniques for accurately manipulating alginate for a final impression for an edentulous arch. Recognize an acceptable final alginate impression of either edentulous arch. Describe the impact of an unacceptable impression on the outcome of the final prosthesis.

C.

Complete Denture Master Casts 1. 2. 3. Describe the appropriate techniques for use of the dental stone used for pouring complete denture master casts. Recognize an acceptable edentulous master cast for either edentulous arch. Describe the impact of various types of unacceptable master casts on the outcome of the final prosthesis.

D.

Complete Denture Bases 1. 2. 3. 4. Recognize acceptable laboratory processed denture bases. Recognize a properly adapted denture base with the use of pressure indicating paste. Identify properly extended denture base flanges. Recognize an adequate or inadequate posterior palatal seal.

E.

Complete Denture Occlusion Rims and Mounting Casts 1. 2. Identify properly contoured occlusion rims prepared for initial jaw relationship records. Identify properly fabricated mounting casts.

F.

Jaw Relationship Records for Complete Dentures 1. 2. 3. 4. 5. Recognize the appropriate sequence for obtaining jaw relationship records and understand the rationale for this sequence. Describe the proper use of a facebow. Describe the techniques for recording centric relation including the materials and their manipulation. Recognize an accurate centric relation record. Recognize what is appropriate lip support, incisal edge length, midline and VDO with occlusion rims.

G.

Esthetic Try In for Complete Dentures 1. 2. Recognize the appropriate sequence for procedures at the esthetic try in appointment and understand the rationale for this sequence. Identify an esthetic denture arrangement including the following: i. Appropriate midline ii. Appropriate shade of denture teeth iii. Appropriate arrangement of denture teeth relative to the smile line, buccal corridor, and plane of orientation. iv. Appropriate lip support and incisal edge length v. Appropriate appearance of vertical dimension Describe the technique for verifying centric relation on the articulator. Describe factors that would indicate the vertical dimension is either excessive or insufficient.

3. 4.

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H.

Processing of Complete Dentures 1. 2. Recognize a properly processed denture. Understand the potential reasons for receiving a denture back from the lab with errors in processing or finishing. Such errors might include the following: i. Porosity of the denture base ii. Flanges shorter or longer than desired iii. Tooth position altered iv. Vertical dimension altered v. Positives or negatives in the denture bases

I.

Delivery of Complete Dentures 1. 2. Recognize a properly fitting denture. Describe the indications for performing a clinical remount and the techniques involved in a clinical remount.

II.

Removable Partial Denture Prosthodontics A. RPD Supporting Tissues: 1. 2. Apply the same criteria as listed in I. 1. above for complete dentures to the supporting tissues for partial dentures. Evaluate teeth and determine their prognosis and potential acceptability as abutments for a partial denture.

B.

Designing RPD frameworks 1. Identify the proper use of all components of an RPD based upon the appropriate principles of design and biomechanics. (Review the corresponding lectures/discussions from the RPD course.) Apply the essential biomechanical principles relative to designing all classifications of partial dentures. Utilize the standard design concepts all classifications of partial dentures.

2. 3.

C.

RPD Mouth Preparation, Impressions, and Master Casts 1. 2. 3. 4. 5. 6. Recognize the indications for altering the axial height of contour on abutment teeth. Describe the appropriate sequencing of mouth preparation. Recognize the appropriate shape and dimensions of occlusal and cingulum rests and describe the consequences if these rests are not correctly prepared. Describe the factors involved in generating an accurate final impression. Recognize an acceptable RPD impression. Identify the properties of an acceptable RPD master cast.

Rev. 12/11

D.

RPD Framework Fabrication and Try-In 1. Create a work authorization for a removable partial denture framework and describe which casts must be submitted and how they must be prepared for fabrication of a removable partial denture framework. List the steps in fitting and seating a removable partial denture framework. Recognize the indications for remaking a framework.

2. 3.

E.

Jaw Relationship Records for RPDs 1. 2. Describe the materials and technique involved in fabricating record bases and occlusion rims for RPDs. Recognize when a record of maximum intercuspation can be used versus a centric relation record for mounting RPDs.

F.

Esthetic Try In RPDs 1. The student should be able to recognize the indications for an esthetic try-in with an RPD. i. The student should be able to apply all the same principles of evaluating esthetics as described above for complete dentures. Describe the principles of RPD occlusion and how to obtain them.

2. G.

Processing of RPDs 1. Recognize how processing may alter the fit the RPD framework.

H.

Delivery of RPDs 1. 2. 3. 4. 5. Recognize a properly fitting partial denture after the acrylic portions have been processed to it. Recognize appropriate occlusion with the RPD and remaining natural dentition. Evaluate properly fitting clasps. Recognize when a RPD needs to be remade. List appropriate post-insertion instructions for the patient.

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IV. Clinical Prosthodontic Program Progress Evaluation

Clinical Expectations and Evaluation Clinical evaluation of student performance in Prosthodontics is intended to be objective and based upon clearly defined criteria. The evaluation system measures the degree of mastery of the student for each clinic session. All clinic sessions are evaluated and all clinic sessions are weighted the same. The procedure performed is not the basis of evaluation. Appropriate performance for the clinic session is the subject of evaluation. Protection of the patient, provision of optimal dental care and efficient clinical education are the goals of the faculty and the focus of the evaluation system. Each clinic session is evaluated by both the student and the faculty. Evaluations are judged as outstanding, acceptable or needs improvement. To successfully complete the clinical phase of prosthodontics, a student must maintain satisfactory progress as recorded by the session evaluations. The students evaluations will be reviewed prior to each APC meeting to assess clinical progress. If the students overall performance indicates several areas for improvement, then appropriate remediation will be developed on an individual basis. The following guidelines must be adhered to by both faculty and students regarding the prosthodontic daily evaluation record in order for it to be an effective measure of activity and ability as well as a tool for communication and feedback. 1) Students will be responsible for presenting forms to faculty at the end of every session, keeping forms in between sessions and delivering forms to the PCCs on the date requested prior to APC meetings.

An email will be sent to remind the class of when the records must be submitted; however, as a rule, they will be due by 5:00 pm on the Monday one week prior to the scheduled APC meeting. (Example: The forms would be
due on Monday, October 17th by 5:00 pm for an APC meeting scheduled for the following Wednesday, October 26th.)

If the student does not submit the records on time, a severe deficiency will be reported to APC.

2)

Students will fill out pertinent information (date, patient, procedure) and complete a self-evaluation prior to giving to faculty for evaluation. Faculty must complete an evaluation for every visitincluding assisting, treatment planning and consults.

3)

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4)

Grades will be in one of three categories:

Outstanding (for exceptional situations) Acceptable (ideally should account for most student evaluations) Needs improvement (for any situation that requires constructive criticismmay cover areas of professionalism, knowledge, clinical skill, patient management, time management, preparedness, etc.)

5)

For any grades of outstanding or needs improvement the faculty MUST include a comment. Comments may be given for acceptable evaluations as well. If a student does not wish to use the same sheet or forgets his/her sheet, there will be extra forms provided in clinic. The forms will also be available on Blackboard. The student must solicit a grade for each session, and QR will be checked to see that the number of sessions match the number of grades submitted. If there are any issues with faculty NOT giving grades, email Dr. Duncan immediately. It is recommended that the student copy his/her sheets before submitting as is suggested for all progress evaluation forms. Dr. Duncan will keep them for the duration of your clinical activity at UCONN.

6) 7)

8)

9)

10)

CATEGORIES FOR ASSESSMENT Knowledge/Clinical Judgment: e.g. Students knowledge base; ability to apply principles or concepts; abilities in critical thinking and decision making, understanding of own limits; ability to work independently or without excessive faculty assistance, etc. Technical Skill: e.g. Student can apply basic concepts or theory to action/practice; exhibits sill in provision of dental care; etc. Professionalism/Patient Management: e.g. Students rapport with patients; interactions with staff and faculty; ethical behavior; general patient management; etc.

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STATEMENTS FOR PROSTHODONTIC CLINICAL EVALUATION Acceptable: a. Student required expected level of assistance for current stage of development and level of experience. b. Student's ability to manage time was acceptable. c. Student displayed appropriate judgment. d. Student displayed adequate clinical skill for current stage of development and level of experience. Needs improvement: a. Student required more assistance than expected for current stage of development and level of experience. b. Student's ability to manage time was unacceptable. c. Student displayed poor judgment. d. Student displayed less than adequate clinical skill for current stage of development and level of experience.

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MINIMAL ESSENTIAL EXPERIENCES The minimal essential experiences for each class can be found on the students homepage on Blackboard. Please be reminded that these are minimal experiences. Students who have been identified as having difficulty progressing through the prosthodontic clinical program may be required to complete additional experiences to show an adequate level of competence (as assessed through the clinic session evaluations and APC reporting.) As a student completes a minimal essential experience, he/she must log it in the tracking book that is kept in the conference room of dental clinic 4. Each class has an appropriately labeled book. When logging information, please include the procedure completed, the tooth or arch worked on, the patients name and TOO number, as well as the date delivered. The faculty you delivered with should then sign the book in the appropriate spot. Information regarding procedures completed in then verified with what has been entered into QR. It is very important to be sure that entries in QR are timely and accurate. NOTE: Credit will not be assigned for procedures that have been incorrectly entered into QR. Please be sure that correct codes are being utilized and that teeth numbers are also correct.

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Community Health Center Crown Experience Tracking Sheet

Student Name: ______________________ Patient Name: Tooth #: ______________________ ________

Preparation approved: __________________________________ CHC Faculty Signature Date Impression approved: __________________________________ CHC Faculty Signature Date Delivery approved: __________________________________ CHC Faculty Signature Date
In order for a student to receive credit for a crown experience (at UCONN or a CHC) the student must complete all procedures from start to finish him/herself. A maximum of 2 crowns completed at a CHC may be applied to the total minimal experiences for prosthodontics. This form should be attached to your prosthodontic experience tracking sheet for UCONN. Be sure to make a copy for yourself!

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