I. Disclaimer

This document is intended to be used as a reference for VA and non-VA providers. It is not intended to replace clinical judgment when determining care pathways. These guidelines do not guarantee benefits or constitute medical advice.

Eligibility for VA dental care is defined by statute and is to be provided in accordance with the provisions of existing law and VA regulations, specifically 38 U.S.C. §§1710(c) and 1712, and 38 CFR §§17.160 through 17.166.

II. Dental Clinical Determinations and Indications

1. Indications for Complex Restorations of the Dentition with or without Implants
2. Complex restorations of the dentition, with or without implants, may be considered clinically necessary when at least ONE of the following criteria are met and documented by the treating or referring dental provider:
   • Failure of Conservative Treatment: Documented failure of conservative conventional fixed or removable prosthetic options, or inability of such options to adequately restore functional impairment, as confirmed by a referring dental provider based on clinical examination or Veteran personal history
   • Presence of Significant Maxillofacial Defect: Indicated only in cases involving significant maxillofacial defects or extensive bone reconstruction (e.g., fibula graft reconstruction), where alternative restoration options are insufficient to achieve functional rehabilitation

2. Limitations/Exclusions
3. Complex restorations of the dentition, with or without implants, are not indicated and therefore considered not clinically necessary when any of the following conditions are applicable:
   • Preference-based selection: Veteran or provider preference for a fixed prosthesis when a less invasive option exists that adequately restores function
   • Minimal occlusal or structural defects: Cases with less than 3 mm of occlusal vertical dimension loss and no significant functional impairment
   • Uncontrolled periodontal disease: Presence of severe periodontal disease without documented successful periodontal therapy
   • High caries risk without prevention: Veterans at high risk for caries who lack adequate preventive measures
   • Severe bruxism without intervention: Cases of severe bruxism without compliance with occlusal splints or other preventive interventions
   • Cosmetic-only indications: Restorations performed solely for aesthetic enhancement without documented functional necessity
   • Insufficient supporting structures: Teeth or implants with poor prognosis due to inadequate bone support, extensive resorption, minimal remaining tooth structure, or questionable restorative prognosis of potential abutment teeth
   • Limited Veteran dexterity: Veterans with physical limitations that preclude adequate maintenance and hygiene of the restoration
   • Posterior fixed partial dentures with minimal functional impact: Requests to replace missing teeth in a quadrant where the absence does not significantly impair masticatory function
   • Incomplete disease control phase: Initiation of restorative procedures prior to completion of the acute and disease control phase of treatment
   • Inappropriate use of third molar as abutment: Use of third molars as abutments unless they occupy the first or second molar position or use of third molar creates a fixed prosthesis that is in occlusion with the opposing dentition

• For all other conditions or indications not listed in section II.a. of this document, complex restorations of the dentition, with or without implants, are considered not clinically necessary due to insufficient evidence of efficacy and safety.

3. Description of Treatment
4. Complex restorations are utilized when it is necessary to restore the function of the teeth in one or multiple sections of the mouth. These procedures may include combinations of crowns, bridges, and dentures with or without implants and are fabricated outside of the mouth. The treatment process typically involves tooth or implant site preparation, impressions or digital scans, and the use of temporary restorations while final restorations are being made. These restorative techniques are typically performed under local anesthesia and aim to address significant functional impairments.

III. Background and Supporting Information

The following information is for reference purposes only in accordance with dental eligibility as defined by statute (law). Each subsection supports VA’s determinations for clinical necessity and alignment with generally accepted standards of dental practice.

1. Background Information
2. Complex restorations, including implant-supported prostheses and multiple indirect restorations, are critical in modern restorative dentistry for addressing extensive functional and structural deficits in the dentition. These restorations are indicated when conservative treatments, such as direct restorations or simpler prostheses, fail to restore function or when significant tooth loss or maxillofacial defects necessitate advanced intervention. Fabricated outside the mouth and secured to natural teeth or implants, these restorations provide durability, stability, and aesthetic outcomes. They are particularly effective for patients with compromised dentition due to trauma, caries, or periodontal disease, improving masticatory efficiency, speech, and quality of life.

2. Research, Clinical Trials, and Evidence Summaries
3. The efficacy and safety of complex restorations are supported by extensive clinical literature. Goodacre et al. (2001) in The Journal of Prosthetic Dentistry emphasize the scientific principles guiding tooth preparations for complex restorations, advocating for precise planning to ensure long-term success. Cascales et al. (2023) in the Journal of Clinical Medicine demonstrates the effectiveness of adhesive restorations in patients with severe tooth wear, supporting their use in complex cases. Gotfredsen and Walls (2007) in Clinical Oral Implants Research highlights the role of implants in restoring oral function, particularly in edentulous or partially edentulous patients.
4. 
   The American College of Prosthodontists (ACP) Parameters of Care (2020) provides comprehensive guidelines for prosthodontic treatments, including complex restorations and implant-supported prostheses. Jemt and Lindquist (1994) in Clinical Oral Implants Research confirm improved masticatory function with fixed implant prostheses. The American Dental Association’s (2023) evidence-based guidelines on restorative treatments further support the use of complex restorations for significant functional impairments. Collectively, these sources validate the indications for complex restorations through clinical expertise, systematic reviews, and primary research.

3. U.S. Food & Drug Administration Information
4. VA generally only approves use of medical devices that have received at least Food & Drug Administration (FDA) clearance for 510(k) Premarket Notification. The FDA has determined these Class II devices are substantially equivalent (SE) to legally marketed predicate devices, in terms of safety and effectiveness, and may be marketed in the U.S. Manufacturers must adhere to FDA regulations on labeling, manufacturing practices, and post-market surveillance. The FDA monitors adverse event reports and can mandate recalls. Manufacturer’s Instructions for Use (MIFU) must be followed.

   Dental implants and restorative materials used in complex restorations are regulated by the FDA’s Center for Devices and Radiological Health (CDRH). Implants are typically classified as Class II medical devices, requiring 510(k) premarket notification to demonstrate equivalence to predicate devices in safety and effectiveness. Restorative materials, such as ceramics and metal alloys, must comply with FDA standards for biocompatibility, durability, and safety under functional loads.

   To search for devices that have received FDA 510(k) clearance or Premarket Approval (PMA), please visit the FDA Devices database.

4. American Dental Association Current Dental Terminology Coding Information
5. The following CDT codes listed in this section are provided for informational purposes only. Inclusion or exclusion of a code does not constitute or imply VA coverage or provider reimbursement. The list of codes may not be all-inclusive since the American Dental Association (ADA) code updates may occur more frequently than dental CDI updates. Please refer to section II.a. in this document to review indications and clinical criteria for clinical necessity.

CPT Code	Description
D6051	Placement of interim implant abutment
D6055	Connecting bar – implant supported or abutment supported
D6056	Prefabricated abutment – includes modification and placement
D6057	Custom fabricated abutment – includes placement
D6058	Abutment supported porcelain/ceramic crown
D6059	Abutment supported porcelain fused to metal crown (high noble metal)
D6060	Abutment supported porcelain fused to metal crown (predominantly base metal)
D6061	Abutment supported porcelain fused to metal crown (noble metal)
D6062	Abutment supported cast metal crown (high noble metal)
D6063	Abutment supported cast metal crown (predominantly base metal)
D6064	Abutment supported cast metal crown (noble metal)
D6065	Implant-supported porcelain/ceramic crown
D6066	Implant supported crown – porcelain fused to high noble alloys
D6067	Implant supported crown – high noble alloys
D6068	Abutment supported retainer for porcelain/ceramic FPD
D6069	Abutment supported retainer for porcelain fused to metal FPD (high noble metal)
D6070	Abutment supported retainer for porcelain fused to metal FPD (predominantly base metal)
D6071	Abutment supported retainer for porcelain fused to metal FPD (noble metal)
D6072	Abutment supported retainer for cast metal FPD (high noble metal)
D6073	Abutment supported retainer for cast metal FPD (predominantly base metal)
D6074	Abutment supported retainer for cast metal FPD (noble metal)
D6075	Implant supported retainer for ceramic FPD
D6076	Implant supported retainer for FPD – porcelain fused to high noble alloys
D6077	Implant supported retainer for metal FPD – high noble alloys
D6082	Implant supported crown – porcelain fused to predominantly base alloys
D6083	Implant supported crown – porcelain fused to noble alloys
D6084	Implant supported crown – porcelain fused to titanium and titanium alloys
D6085	Interim implant crown
D6086	Implant supported crown – predominantly base alloys
D6087	Implant supported crown – noble alloys
D6088	Implant supported crown – titanium and titanium alloys
D6089	Accessing and torquing a loose implant screw – per screw Accessing and retorquing loose implant screw – per screw
D6090	Repair of implant/abutment supported prosthesis
D6091	Replacement of replaceable part of semi-precision or precision attachment of implant/abutment supported prosthesis, per attachment
D6092	Re-cement or re-bond implant/abutment supported crown
D6096	Remove broken implant retaining screw
D6098	Implant supported retainer-porcelain fused to predominately base alloys
D6099	Implant supported retainer for FPD-porcelain fused to noble alloys
D6114	Implant/abutment supported fixed denture for edentulous arch – maxillary
D6115	Implant/abutment supported fixed denture for edentulous arch – mandibular
D6116	Implant/abutment supported fixed denture for partially edentulous arch – maxillary
D6117	Implant/abutment supported fixed denture for partially edentulous arch – mandibular
D6118	Implant/abutment supported interim fixed denture for edentulous arch – mandibular
D6119	Implant/abutment supported interim fixed denture for edentulous arch – maxillary
D6121	Implant supported retainer for metal FPD – predominantly base alloys
D6122	Implant supported retainer for metal FPD – noble alloys
D6191	Semi-precision abutment – placement
D6192	Semi-precision attachment – placement
D6193	Replacement of implant screw
D6194	Abutment supported retainer crown for FPD – titanium and titanium alloys
D6195	Abutment supported retainer – porcelain fused to titanium and titanium alloys
D6197	Replacement of restorative material used to close an access opening of a screw-retained implant supported prosthesis, per implant
D6198	Remove interim implant component
D6205	Pontic – indirect resin based composite
D6210	Pontic – cast high noble metal
D6211	Pontic – cast predominantly base metal
D6212	Pontic – cast noble metal
D6214	Pontic – titanium and titanium alloys
D6240	Pontic – porcelain fused to high noble metal
D6241	Pontic – porcelain fused to predominantly base metal
D6242	Pontic – porcelain fused to noble metal
D6243	Pontic – porcelain fused to titanium and titanium alloys
D6245	Pontic – porcelain/ceramic
D6250	Pontic – resin with high noble metal
D6251	Pontic – resin with predominantly base metal
D6252	Pontic – resin with noble metal
D6253	Interim pontic – further treatment or completion of diagnosis necessary prior to final impression
D6545	Retainer – cast metal for resin bonded fixed prosthesis
D6548	Retainer – porcelain/ceramic for resin bonded fixed prosthesis
D6549	Retainer – resin bonded fixed prosthesis
D6600	Retainer inlay – porcelain/ceramic, two surfaces
D6601	Retainer inlay – porcelain/ceramic, three or more surfaces
D6602	Retainer inlay – cast high noble metal, two surfaces
D6603	Retainer inlay – cast high noble metal, three or more surfaces
D6604	Retainer inlay – cast predominantly base metal, two surfaces
D6605	Retainer inlay – cast predominantly base metal, three or more surfaces
D6606	Retainer inlay – cast noble metal, two surfaces
D6607	Retainer inlay – cast noble metal, three or more surfaces
D6608	Retainer onlay – porcelain/ceramic, two surfaces
D6609	Retainer onlay – porcelain/ceramic, three or more surfaces
D6610	Retainer onlay – cast high noble metal, two surfaces
D6611	Retainer onlay – cast high noble metal, three or more surfaces
D6612	Retainer onlay – cast predominantly base metal, two surfaces
D6613	Retainer onlay – cast predominantly base metal, three or more surfaces
D6614	Retainer onlay – cast noble metal, two surfaces
D6615	Retainer onlay – cast noble metal, three or more surfaces
D6624	Retainer Inlay – titanium
D6634	Retainer Only – titanium
D6710	Retainer crown – indirect resin based composite
D6720	Retainer crown – resin with high noble metal
D6721	Retainer crown – resin with predominantly base metal
D6722	Retainer crown – resin with noble metal
D6740	Retainer crown – porcelain/ceramic
D6750	Retainer crown – porcelain fused to high noble metal
D6751	Retainer crown – porcelain fused to predominantly base metal
D6752	Retainer crown – porcelain fused to noble metal
D6753	Retainer crown – porcelain fused to titanium and titanium alloys
D6780	Retainer crown – 3/4 cast high noble metal
D6781	Retainer crown – 3/4 cast predominantly base metal
D6782	Retainer crown – 3/4 cast noble metal
D6783	Retainer crown – 3/4 porcelain/ceramic
D6790	Retainer crown – full cast high noble metal
D6791	Retainer crown – full cast predominantly base metal
D6792	Retainer crown – full cast noble metal
D6793	Interim retainer crown – further treatment or completion of diagnosis necessary prior to final impression
D6794	Retainer crown – titanium and titanium alloys
D6920	Connector bar
D6930	Re-cement or re-bond fixed partial denture
D6940	Stress breaker
D6950	Precision attachment
D6980	Fixed partial denture repair necessitated by restorative material failure

Current Dental Terminology (CDT), Copyright ^© 2026 American Dental Association. All rights reserved.

IV. Definitions

Term	Definition
Abutment	A structure that receives thrust or pressure, supporting or retaining a prosthesis
Abutment supported crown	A crown attached to an abutment, not directly to the implant post
Cantilever fixed dental prosthesis	A fixed prosthesis where the pontic is retained and supported only on one end by abutments
Complex restorations	More than one indirect restoration, implant, or fixed partial denture in a quadrant
Connector bar	A device attached to a fixed partial denture retainer or coping to stabilize and anchor a removable overdenture
Fixed dental prosthesis	A prosthesis securely fixed to natural teeth or implants, removable only by a dental provider
Implant supported crown	A crown attached directly to the implant post
Implant/abutment supported fixed denture (Hybrid)	A fixed prosthesis fully supported by implants, removable only by a dental provider
Implant/abutment supported removable denture (Overdenture)	A removable prosthesis secured to implants via clips, snaps, or locators for enhanced comfort and function
Pontic	An artificial tooth in a fixed dental prosthesis that replaces a missing tooth and restores function
Precision attachment	An interlocking device fixed to an abutment, integrated into a removable prosthesis for stabilization
Resin-bonded prosthesis	A fixed prosthesis luted to etched enamel for mechanical retention (e.g., Maryland Bridge)
Stress breaker	A component of a prosthesis designed to relieve abutment teeth from harmful stresses

V. References

American College of Prosthodontists. (2020). Parameters of Care for Prosthodontics. Journal of Prosthodontics, 29(S1), 3–147.

American Dental Association. (2023). Evidence-based clinical practice guideline on restorative treatments for caries lesions. Journal of the American Dental Association, 154(7), 551–566.e51.

American Dental Association. (2024). CDT Codebook. ADA.

Cascales, A. F., Sauro, S., et al. (2023). Total rehabilitation using adhesive dental restoration in patients with severe tooth wear: A 5-year retrospective case series study. Journal of Clinical Medicine, 12(16), 5222.

Goodacre, C. J., Campagni, W. V., & Aquilino, S. A. (2001). Tooth preparations for complete crowns: An art form based on scientific principles. Journal of Prosthetic Dentistry, 85(4), 363–376.

Gotfredsen, K., & Walls, A. W. (2007). What dentition assures oral function? Clinical Oral Implants Research, 18(Suppl 3), 34–45.

Jemt, T., & Lindquist, L. W. (1994). Masticatory function in edentulous patients treated with fixed prostheses. Clinical Oral Implants Research, 5(3), 162–168.

U.S. Food and Drug Administration. (2024). Dental ceramics – performance criteria for safety and performance-based pathway: Guidance for industry and Food and Drug Administration staff. FDA.

VI. Dental CDI History/Revision Information

Date	Summary of Update(s)
07/01/2026	New dental CDI created describing clinically necessary and not clinically necessary indications

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