Removable Prosthodontics

Chairperson

• Judith Jones, DDS, MPH, DScD

Divison Director

• Jean S. Emerling, DDS

Clinical Faculty

• Joseph Calabrese, DMD
• Pelly Chang, DMD
• Dorothy Gurin, DMD
• Thomas Hawley, DMD
• Ghassan Khoury, DMD
• Bing Liu, DMD
• Andrea Maalouf, DMD
• Steven Roberts, DMD
• Ronni Schnell, DMD
• Sein Siao, DMD
• Kanwar Deep Singh, DMD
• Tina Valades, DMD
• Dawn West, DMD

Laboratory Technician

• Leila Joy Rosenthal, CDT

Laboratory Assistant

• Fran Zaremba

Administrative Assistant

• Carole Green

Clinic Hours

• Monday 8:30 a.m.– 7 p.m
• Tuesday 8:30 a.m.– 7 p.m.
• Wednesday 8:30 a.m.– 7 p.m.
• Thursday 8:30 a.m.– 7 p.m.
• Friday 8:30 a.m.– 4:30 p.m.
• Saturday 8:30 a.m.– 3:30 p.m.

Location

• Room 619

Telephone

• 617/638-5209 (4690)

Introduction

This course is designed to provide a broad background in the theory and fabrication of Removable Complete and Partial dentures. Emphasis is placed on diagnosis, design and patient management. Before patient treatment can begin, a student must give evidence of competency in preclinical courses in both complete and partial dentures. The information in this section of the Clinic Manual contains all clinic protocols and forms.

Contents

Departmental Forms (also available at fifth-floor desk)

Appliance Code

The use of the following abbreviations is required for all record keeping and business office purposes:

• Complete Denture = CU or CL
• Partial Denture = PU or PL
• Immediate Denture = IU or IL
• Transitional Denture = TU or TL
• Overlay Denture = OU or OL
• Reline or Rebase = RU or RL
• Repair = XU or XL
• Natural Dentition = NU or NL
• Two appliances are indicated as: _U / _ L

Appointments (Office)

• Scheduling method:  Appointments may be made with the division director by referring to the sign-up sheets posted outside the department office.
• Required appointment
  • Designing Partial Dentures
  • Sending cases to lab for Framework fabrication
• non-appointments
  • Occlusion check prior to processing.
  • Abutment wax-up or casting surveys.
  • Signing out of the Department.

Armamentarium

• The following items must always be chairside when treating a patient, regardless of what treatment is being performed. Failure to have these items inconveniences the student, the faculty, and the patient. It results in treatment delays and may, at the discretion of faculty, result in termination of the appointment. Click here for required items for specific procedures:
  • Patient Record
  • Removable Folder
  • #6 Bard-Parker knife
  • Sterile Mirror
  • Wax
  • Spatula
  • Alcohol
  • Torch
  • Sterile Explorer
  • Tongue Blade
  • Napkin on Bracket Tray
  • Napkin on Patient
  • Gloves
  • Indelible Pencil
  • Sterile T-ball Burnisher
  • Protective Eyewear
  • Evaluation form
• laboratory. The following items must always be brought to the laboratory, regardless of what procedure is being performed:
  • Protective Eyewear
  • Plaster Knife
  • Patient Flow Sheet
  • Plaster Spatula
  • Vaseline and Brush
  • Plaster Bowl

Castings

• abutment  
  • Abutment castings must be surveyed by the Removable faculty prior to final cementation. This does not require an appointment and may be done at any mutually convenient time.
  • All rest seats and guide planes must be metal, regardless of the casting material for full crowns.
  • All castings must be permanently cemented prior to partial denture final impressions.
  • Castings to be done by a laboratory must be accompanied by full arch tripodded master die model.
• partial dentures 

Complete Denture Protocol

• Credit units are units that have been completed by a student under faculty supervision. They are the components of Baseline Learning.
• insertion protocol
  • No denture may be inserted during the last week of a semester, or day of a week.
  • No immediate dentures may be inserted during the last two weeks of a semester.
• immediate protocol
  • students:
    • Must work with one instructor after CR. Must have a duplicate model on which all alveoloplasties can be outlined for the Oral Surgeon.
    • Must fabricate a clear acrylic template for all cases. (cont’d next page)
    • Must obtain a Removable faculty permission signature on Treatment Plan page before making an OS appointment.
    • Must schedule extractions and insertions on Monday or Tuesday mornings, unless written permission from Removable faculty appears in the patient record.
    • Must inform Removable faculty on the OS appointment day before extractions begin that their patient will require attention. Dentures must be inserted as soon as possible after surgery.
    • Must schedule a post insertion adjustment within the first 24 hours following surgery.
    • Must obtain written permission when another department or student will do insertion or adjustments.
  • removable faculty:
    • Must add the following step to the Treatment Plan for Immediate Denture patients: “Review of Immediate dentures/signature by Removable Faculty.”
    • Must sign permission for the extraction appointment on the Treatment Plan page. This means that the denture and template are ready.
  • mentors:
    • Must add the following step to the Treatment Plan for Immediate Denture patients: “Review of Immediate dentures/signature by Removable Faculty.” SURGICAL FACULTY AND RESIDENTS
    • Must check the Treatment Plan page for the permission signature for extraction from the Removable Department before performing any extractions for Immediate Dentures.
    • Must ask to see Denture and Template before surgery.
  • appointment personnel:
    • Must check the record for permission signature for extractions from the Removable Department before appointing the Immediate Denture patient.
    • Whenever possible, schedule these procedures for Monday, Tuesday or Wednesday mornings, unless permission signature from Removable allows for variation.
    • Schedule extractions between 8-10 or 11-12:30 to permit a minimum of 1 hour of chairside time for Insertion of appliance on the 5th floor.
• team dentures protocol
  • Two students may share a single patient who requires a conventional CU/CL. No other appliance may be substituted.
  • Each student will receive 2 units of complete denture credit.
  • A student may only do one CU/CL as a Team unless authorized.
  • All work must be done simultaneously by both students for either to receive any credit.
  • Two green forms (Flow Sheet) are used for Team Dentures. One is kept in each student’s folder.
  • The “A” Set of CU/CL will be inserted.
  • A second set of team dentures may be done by a team of students if :
    • Team partners are new.
    • The patient is new (for both students).
    • The “A”/”B” arrangement changes from the one used previously (a student may be “A” only once or “B” only once).
    • Permission/verification is made in the patient record by a mentor.
  • Advanced Standing Students may do only one set as a team.
• free second set. Any complete denture arch (including Immediate and Overlay) can have a second free denture if payment proof for the original appliance is given.
• denture labels. Dentures of welfare and nursing home patients must bear the patient’s name and/or social security number.    
  

Consultations

• Prior to treatment planning removable Partial appliances, a signed consultation will be required in Periodontics and Operative.
• Consultations may be required in Oral Surgery, Endodontics and Fixed Prosthodontics.
• For complete dentures, Oral Surgery or Endodontic consultation may be required.
• For a complete denture where no other treatment is required, a Removable consultation alone is needed.
• All necessary consultations must be done prior to treatment planning.
• Removable consultations are of 2 types:
• Chairside
• Survey & Design (see Partial, Survey & Design Consultation)

Credit/Case/Unit Definition

• Complete Denture
  • One (1) unit of Complete Denture equals one (1) arch of:
    • Complete denture
    • Immediate denture
    • Overlay denture
  • One-half (1/2) unit of Complete Denture equals one (1) arch of :
    • Reline or Rebase (CD or PD)
    • Transitional partial denture
    • Interim denture
  • Repair (based on degree of difficulty)
  • A minimum of four (4) units or two (2) sets of CU/CL dentures is required to form an adequate basis for competency evaluation.
• Partial Denture
  • One (1) unit of Partial Denture credit equals (1) arch of Partial Denture.
  • In order to qualify as a Partial Denture credit, the fabrication of Framework must be included.
  • A 2 unit minimum is needed to form an adequate basis before testing
• Completion Requirement: Credit will be awarded only when given a “case completed” faculty signature. Completion of work is considered a necessary part of good patient care. A case is “completed” when the faculty determines the case can be placed on 6-month recall.
• No Credit: No credit will be given for unauthorized treatment or for treatment of an unauthorized patient. “Credit” thus implies authorized work, which is available for evaluation.

Disciplinary Action

Disciplinary action will be taken in the event that a student renders removable treatment without:

1. Authorized treatment plan.
2. An instructor present in the clinic.
3. A signed contract for the treatment performed.
4. Officially being assigned the patient (other than for emergency procedure).
   

Emergencies

• Assigned Patients: Students are responsible for treating emergencies for their assigned patients unless they are on an outside rotation. While on rotation, the patient must be officially transferred (temporarily or permanently) to another student. (see Patients)
• Emergency Rotation: Credit will be given for procedures performed while on emergency rotation if they are properly documented using the “flow sheet” protocol.
• Walk-in repairs:
  • If simple or patient is in pain, perform repair.
  • If complex and/or patient not in pain, either reappoint or have patient services assign patient to a student.

• Competency-Based Evaluation: Evaluation is based upon the achievement of specific clinical competencies related to Removable Prosthodontics that measure quality, consistency and independence of performance.
• Competency Statement: Graduates must be competent in the replacement of missing teeth to form, function and esthetics in the uncomplicated adolescent, adult, geriatric and medically compromised patient.
• Competencies in Removable Prosthodontics:  In order to give evidence of competency in Removable Prosthodontics, the graduate must be able to:
  • Diagnose and Treatment Plan Removable or Fixed-Removable combined restorations, or recognize, when necessary the need to refer.
  • Perform those clinical procedures necessary to fabricate a Removable Complete or Partial denture, including temporization.
  • Perform those l aboratory procedures necessary to fabricate a Removable Complete or Partial denture, or, utilizing a work authorization, direct and evaluate the fabrication of same by a laboratory technician.
  • Develop an occlusal scheme according to the requirements of natural and/or artificial dentitions.
  • Re-evaluate and manage the correction of conditions secondary to the placement of Removable Complete and Partial dentures.
• Formative Feedback & Evaluation
  • Daily Feedback is given to the student in the form of a non-graded record of clinical performance. The are areas recorded relate specifically to the Competencies in Removable Prosthodontics mentioned above. (See Clinic Journal and Qualifiers & Milestones for Summative Evaluation)
  • The Feedback gives evidence of Faculty-Student Interaction as well as Patterns of Performance toward competency.
  • In order to obtain sufficient data for Evidence of Patterns, a Baseline Learning Level of procedures is recommended.
  • During completion of Baseline Learning the student’s Pattern of Performance toward Competency is evaluated by referring to the Clinic Journal.
  • Enrichment Activities (e.g., lab exercise, tutoring, remediation, and deceleration) are scheduled by the Director to address Poor Performance Patterns.
• Summative Evaluation & Grading
  • Daily Feedback is evaluated as Evidence of a Pattern toward Competency. Once evidence of a Pattern toward competency is established, the student is allowed to begin Graded Exercises.
  • The grading criteria are related to specific performance levels for all competencies listed above. (See Qualifiers & Milestones for Summative Evaluation)
  • Graded Exercises include:
    • Skill Tests (see Summative Evaluation Form)
    • Competency Exams (See Summative Evaluation Form)
    • Oral Examination
  • The following items are utilized in determining a student’s Achievement of Competency:
    • Direct Clinical Observation (Daily Performance)
    • Removable Prosthodontics Log (Flow Sheets)
    • Skill tests (See Summative Evaluation Form)
    • Oral Examinations of Case Design
    • Record Reviews (random sampling)
    • Externship Performance Evaluation
    • Student Self Evaluation
    • Other Achievements (Case Documentations, presentations)
  • Modifying factors include:
    • Degree of Difficulty
    • Use of “Equivalent” activities in cases of patient maldistribution or small sample size
    • Rate of improvement
    • Level of knowledge attained (ability to analyze, synthesize, and evaluate)
  • Grading criteria are listed separately for third-year (DMD III), fourth-year (DMD IV) and Advanced Standing Students (AS II) (See Qualifiers & Milestones for Summative Evaluation)

• To do Removable (Complete or Partial), a student must have completed an equivalent case at school or have permission from the Division Director.
• To receive formative credit:
  • Procedures must be documented on Flow Sheets, including “case completion” signatures.
  • Partial Denture designs must accompany Flow Sheets.
  • Stone casts must be made of all appliances and opposing occlusion. They must be mounted on a semi-adjustable articulator and presented for evaluation.
• Formative Credit given:
  • Up to 4 units of Complete Denture
  • Up to 2 units of Partial Denture
  • 100% of points earned
• Folders must be given to Department Office Secretary before departure.

Folders  

• Contain Patient Flow Sheets for all assigned patients (Active & Inactive)
• Provide departmental record of treatments, independently of patient record.
• Permit periodic review of student performance.
• Provide feedback to student of quantity and timeliness.
• Are not substitutes for patient treatment record.

• Students going on home visits must follow the protocol of the Geriatric Dentistry Program.
• Documentation of procedures can be made using Flow Sheets.
• In order to enter data in the computer, Flow Sheets must be signed by the accompanying faculty member or Division Director at case completion.
• Data entry can be performed using Flow Sheets for patients not treated on school premises. This can be done by accompanying faculty or Director.

• All laboratory work, except Partial Denture castings and denture processing, must be performed by the student.
• Lab work done in the technicians' lab will be done by appointment only, except for emergencies.
• Commercial laboratory procedures must include:
  • A properly written and signed work authorization in duplicate
  • A properly tripodded master cast with undercuts marked. (for PD)
• To send a Partial Denture case to a commercial lab, an appointment must be made with Division Director or designee. The items required at this time are:
  • Patient record
  • Removable Folder
  • Final cast (mounted unless edentulous opposing arch)
  • Counter model (unless edentulous)
  • Written Work Authorization
• Partial Denture cases which include facings must also be accompanied by:
  • Facing
  • Matrix
  • Semi-adjustable articulator
• Steele's facings – items needed for cementation:
• Framework
• Final Cast
• Facing
• Matrix
• Tooth colored cold cure acrylic

• Before Treatment Planning
  • All necessary interdepartmental consultations must be entered in patient’s chart and signed by design instructor.
  • A partial denture design must be entered in patient’s chart and signed by an instructor.
• Designing a Partial Denture Requires
  • Patient Record
  • Removable Folder
  • Preliminary casts (mounted unless edentulous opposing arch)
  • Survey & Design Form
  • Surveyor
  • red/blue pencil
• Fixed/Removable Cases. Must be mounted and submitted with patient record to both Director of Fixed and Removable divisions for evaluation prior to treatment planning.
• Record of the Design. Written copies of the design must total 3:
  • One copy is in patient’s record
  • One copy is attached to patient’s flow sheet
  • One copy is sent to the laboratory
• Commercial Laboratory Authorization. Sending a Partial Denture to lab requires:
  • Patient record
  • Removable folder
  • Final casts
  • Counter model (unless edentulous)
  • Written Work Authorization
  • Proof of payment (Business Office Authorization)
• Provisional/Transitional Partial. In the interest of better patient care, no Provisional/Transitional Partial Dentures may be treatment planned or contracted without:
  • Definitive treatment plan for cast partial denture.
  • Signed design for cast partial denture.
  • Signed contract for cast partial denture
  • Written authorization from division director for any exceptions.
• Altered Cast Impressions. Unless authorized by an instructor, all mandibular distal extensions will be impressed using the Altered Cast Technique.

Patients

• Transfer
  • Transfer of patients from one student to another may be done by mentors only. Any direct student to student transfer is strictly forbidden. Failure to comply will result in:
    • Disallowing any credit for work done.
    • Disciplinary action.  
  • Graduating students must transfer incompleted cases or those having received Immediate or Provisional treatment.
  • To request a patient transfer the student must e nter the reason in the patient record and have a removable instructor’s signature.
• Discontinuation
  • To discontinue a patient the student must enter the reason in the patient record and have it signed by a Removable instructor.
• Patients Referred by Students
  • Students who produce their own patients will be assigned these patients if, prior to the initial visit, the students:
    • Inform Patient Services or Mentor.
    • Inform Oral Diagnosis.
    • Inform the patient.
  • Patient will be transferred only for reason of difficulty.
• Patients Interviewed on Screenings
  • Students who wish to participate in screenings may select one (1) Removable patient per screening.
  • Students on Oral Diagnosis Rotation are not entitled to patients seen on Rotation.
• Patient Complaints
  • If a patient phones the departmental office complaining about loss of contact with an assigned student, that patient will automatically be reassigned and the student notified.
  • If a patient complains directly to a student, such complaints should be documented in the patient record. Such complaints will be handled jointly by student, instructor and division director.
  • If a patient complains to the division or department secretary all evidence will be examined before a course of action is determined.

• Contracts
  • No contract may be signed without a signed Treatment Plan
  • No work may be performed without a signed contract (except in an emergency)
  • The signature should be placed by the fif th floor or business office personnel
  • Be absolutely certain every case has this signature before starting/continuing treatment.
• Payment Policy
  • Contract signed and 50% of total charge paid before final impression.
  • Complete Denture Balance: paid in full before insertion.
  • Partial Denture Balance: paid in full before final cast is sent to lab.
• Student Responsibility. Student bears the responsibility for appliances delivered to patient with unpaid balances.
• Additional Charges
  • Gold Partial framework
  • Open face crowns/Gold crowns on Dentures.
• Fee Waiver. Reduction or refund is at discretion of division director or department chair only.

Records

• Patient Record. Signed and co-signed entries must be entered for any:
  • Treatment rendered
  • Treatment plan, change of plan
  • Appointment failing with written explanation
  • Transfer of patient
  • Discontinuation of patient
• Removable Folder. Where appropriate, all items listed above must be noted and signed on the individual patient flow sheet kept in the removable folder.

• Procedures are defined as “units” of complete or partial dentures. The definition or value of units is described under credit.
• All students must complete the equivalent of two units in the third year. This allows for the collection of adequate baseline data.
• The overall third year and fourth year protocol is as follows: after satisfactory completion of specified baseline learning levels, successful completion of one of the competency testing level options must be completed. See objectives.
• Competency Testing levels must be selected for both complete and partial dentures to sign out of the Division of Removable Prosthodontics.
• Complete dentures done as Option I Exams (new patients) will be delivered to patients and appropriate fee charged. Those done as Option II Exams (previous patients) will be done at no charge.
• Testing level options are ultimately the choice of the student. Practical or Oral Examinations, however, may be arranged only through approval of the Division Director and require proof of completed work to date, patient record review for treatment plan or fee verification.

While on clinical Rotations, such as Externship, Radiology, Oral Surgery, Prevention Center, a student must ensure that either:

• Patient is transferred if care will be interrupted for a significant time.
• Patient is referred to another student for emergency care.
• Patient is fully informed of the situation.
• Folder is brought to Department Office (Externship only)

• Print out your Summative Exam Results and put them in your folder.
• Get all Case Completion Signatures on Flow Sheets.
• Get all Business Office Signatures on Flow Sheets.
• Bring Patient Record with Remo faculty approval for any Patient Transfer.
• Bring any Appliances that need to be transferred.
• Bring copies of Partial Denture Designs.
• Bring Patient Record for all Immediate or Transitional appliances.
• Meet with either Dr. Emerling, Dr. Maalouf, Dr. Roberts or Dr. Schnell.

• Before removing prosthesis from Operatory, disinfect according to the Infection Control Manual.
• Before performing any laboratory procedure on a prosthesis, disinfect according to the Infection Control Manual.

• All clinic-related supplies should be obtained from the fifth floor dispensing window. Supplies in the sixth floor lab are for preclinical use only.

• Complete Denture: Hickey, Barb & Blender: “Boucher’s Prosthodontics Treatment for Edentulous Patients,” 11 th ed. (1997).
• Partial Dentures: McGiveny & Castleberry: “McCracken’s Removable Partial Prosthodontics,” 12th Ed. (2005)

Tooth Orders

When a tooth shade and model has been selected for a patient and co-signed by an instructor, orders are placed with a laboratory technician.

Treatment Plans

No treatment may be performed without a Treatment Plan. No contract may be signed without a signed Treatment Plan.  

• Treatment Plan Signatures. Treatment Plans must be signed by the Department of Oral Diagnosis with one exception. In case of CU/CL, where no other treatment will be needed, a Removable Instructor can, in the interest of saving time, sign the Treatment Plan.
• Treatment Plan Changes. Any changes in the Treatment Plan must be signed by the Removable instructor and co-signed by a mentor.  

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