PROSTHODONTIC LABORATORY PROCEDURES A. Objectives: 1. Develop a level of competency in all laboratory aspects of prosthodontic treatment.
2. Develop the ability to manage and train ancillary personnel or semi-skilled technicians in all prosthodontic laboratory procedures.
3. Develop a working knowledge of the administrative procedures required to run a laboratory.
B. Guidelines: 1. The first year resident will complete all laboratory procedures for patients they are treating until demonstrated competency is reached.
2. The second and third year residents may utilize the clinic laboratory or the Dental School Laboratory for some procedures as permitted by the Program Director. Exceptions include mock board patients, for whom, the residents will complete the required laboratory work.
VII. STANDARDS TO ASSESS OUTCOMES Purpose and objectives of the Prosthodontic Residency Program:
A. Planning and Evaluation Process The planning and evaluation process of the prosthodontic program encompasses a broad based involvement of the faculty and administration. The Department Chairman, program director, faculty, and current and past residents have input into the planning and evaluation process. Specific guidance is obtained from the American Dental Association, Standards for Advanced Specialty Education Programs in Prosthodontics. Additionally, an annual mentors conference sponsored by the American College of Prosthodontists provides for an update on a variety of applicable topics.
B. Mentor Evaluation of Resident 1. The residents are evaluated by the mentors using both qualitative and quantitative criteria.
a. Qualitative - (Pass - Fail)
1) Meets Program Standards
2) Fails to Meet Program Standards
b. Quantitative - (Letter grades)
A = Outstanding
B = Satisfactory
C = Unsatisfactory
I = Incomplete
2. Reports and test results that are done throughout the year.
a. Residents Evaluation Report - A quarterly report on each resident assessing academic, clinical, and personal performance.
b. Presentation Reports - Critiques will be done by the mentors after each resident presentation. Approximately 8 per year.
c. Mock Boards - Comprehensive written and oral examination and patient presentation. Two times a year.
d. Course grades - Results of formal didactic courses.
e. Periodic Quizzes - Designed to determine if students are learning and retaining new material.
f. Periodic Oral Challenges - Designed to help determine how well students are grasping new concepts and ideas.
C. Assessment of Resident Clinical and Academic Achievement 1. Knowledge Outcomes: Understanding general facts specific to a particular field; understanding processes, theories, and methodologies.
Methods of Assessment:
a. Results of written exams
b. Results of oral exams
c. Results of oral presentation evaluations
d. Results of Standards of Care Evaluations by mentors
e. Results of quarterly written reports by mentors
2. Skills Outcomes: Attainment of academic, communication, leadership/interpersonal, vocational, manual, and other skills.
Methods of Assessment:
a. Results of Standards of Care evaluation by mentors
b. Results of oral presentation evaluations
c. Results of quarterly written reports by mentors
3. Values and Beliefs: Development of effective characteristics appropriate to a graduate of the program. Development of a format to assess the attitudes and satisfaction of residents in regards to their program.
Methods of Assessment:
a. End of year critique by residents
b. End of program critique by residents
c. One year post graduation critique by former residents
e. Results of quarterly written reports by mentors
4. Relationships/Behavioral Measures: Achievement of a productive and cooperative mentor/resident relationship; compatible clinician/dental assistant or laboratory technician relationship.
Methods of Assessment:
a. Academic probation rates
b. Attrition/withdrawal rates
c. Success of candidates in obtaining specialty board certification
d. Results of one year post-graduation critique
(Standards of Care) A.Medical-Dental History and Treatment Plan: A thorough and complete medical and dental history is obtained from the patient and the patient's dental record to include required medical and/or dental consultations. Any medical or dental conditions are considered in the treatment plan. The plan is based on sound prosthodontic procedures. The resident is technically capable of completing the proposed plan with staff supervision. The patient is in agreement with the plan and understands the time required to complete it.
B. Diagnostic Casts: Are accurate, clean, bubble-free reproductions of the existing dental anatomy. Casts should be properly related on an appropriate articulator.
C. Anesthesia: Local anesthetic should be administered correctly, gently, and in proper amounts so that the prosthodontic procedure can be completed in a pain free environment.
D. Preparations: Should be completed to provide for proper retention and resistance form and to provide adequate thickness of metal and/or porcelain to develop optimal occlusion, contours, and esthetics.
E. Retraction: Retraction of soft tissues should be accomplished gently with a minimal of trauma to the gingival tissue. All tooth margins should be exposed and all hemorrhage controlled.
F. Final Impressions: Must have an accurate, non-distorted reproduction of all required dental structures with clearly defined, void-free margins of all tooth preparations.
G. Jaw Relation Records: Records should accurately reproduce centric relation occlusion when working casts are articulated. Records should be of an appropriate material to allow handling by laboratory personnel without distortion or fracture.
H. Provisional Restorations: Provisional crowns or fixed partial dentures of an acceptable material should be placed on all preparations to cover exposed dentin. Contours and contacts should promote gingival health and maintain tooth position. Occlusion should be comfortable and adequate to prevent eruption of opposing dentition or preparations. Esthetics of anterior provisional restorations should be acceptable within the limitations of the material used.
I. Laboratory Procedures: 1. Working casts should be trimmed, smoothed, and free of all bubbles and voids. Land areas of working casts should be trimmed and rounded.
2. Dies are to be trimmed in a manner prescribed by the Fixed Prosthodontic mentor in order to expose and clearly delineate all margins. Margins are to be marked with red pencil. Die spacer in the appropriate thickness should be applied to all dies to within 1mm of the margin. Casts should be articulated prior to placing die spacer when an interocclusal record is used.
3. Articulating Indices: All jaw relation records should be trimmed so that cusp tips only occlude with the record and in such a way that the laboratory technician can assure that all teeth fit the record. Occlusal indices should be marked on both maxillary and mandibular casts with colored pencil or cut with a separating disk.
4. Prescription Forms: All laboratory prescription forms should be completed to include appropriate information. All prescription forms going to another laboratory must be countersigned by a prosthodontic mentor and logged in.
J. Try-In: 1. Margins: All crown margins should be closed as is reasonably and clinically detectable by use of an explorer.
2. Contours: All crown contours should replicate the patient's ideal natural tooth as closely as possible. Crowns should be measured buccal-lingually and cusp to cusp to prevent overcontouring.
3. Contacts: Contact should not allow the easy passage of dental floss. Lack of contact (if applicable) constitutes a remake or the addition of porcelain or solder.
4. Occlusion: All restorations should restore the proper occlusal plane of the patient. This may include recontouring or restoration of the opposing dentition or prostheses. All prostheses should contact in centric occlusion or maximum intercuspation to hold shim stock (12mu) firmly. All non-restored teeth both ipsilateral and contralateral should also hold shim stock firmly. Restorations should be free of lateral interferences in accordance with the patient's occlusal scheme, i.e., group function, canine disclusion, etc.
5. Shade: Porcelain shades should be esthetically acceptable to the patient.
6. Porcelain Characterization: Extrinsic coloration will be added to porcelain restorations as required to more closely match the natural dentition. Porcelain restorations should be glazed without vacuum to the appropriate smoothness and finish and match the patient's dentition. Porcelain may be polished instead of glazed in small areas.
7. Polish: All metal surfaces are to be free of scratches and oxidation, and be smoothed and highly polished prior to cementation.
K. Cementation: Final restorations are to be cemented with an appropriate cement as outlined by the mentors. All excess cement must be removed prior to dismissal of the patient.
L.Patient Management: All patients in Prosthodontics should be treated in accordance with the highest professional standards. Derogatory comments or negative comments will not be made. Any questions concerning patient treatment should be discussed in private with the appropriate mentor.
M. Time Management: Residents should pre-plan all prosthodontic treatment prior to their rotation day. Residents should arrive on time, begin treatment promptly, and complete treatment in an expeditious manner. All laboratory procedures should be accomplished to allow the laboratory technicians ample time to meet the delivery date.
N. Standards of Care: All patients will be evaluated using the appropriate standards of care form.
STANDARDS OF CARE EVALUATION FORM
Patient's Name __________________________________
Acceptable Needs Impr. Unacceptable
1. Patient's Medical & Dental
History & Treatment Plan
2. Diagnostic Casts
6. Final Impressions
7. Jaw Relation Records
8. Provisional Restorations
9. Laboratory Procedures
Bubbles, dust, voids
3) Positional record
4) Articulated casts
5) Custom incisal guide
Acceptable Needs Impr. Unacceptable
1) Axial reduction 2) Occlusion reduction
6) Stability of dies _________ __________ ___________
c. Laboratory Prescription:
1) Patient data
2) Facial margin type
3) Special instructions 10. Try-In:
d. Occlusion e. Shade f. Characterization
12. Patient Management
13. Time Management
Treatment Assessment Performance Standard Assessment 1. Acceptable Resident:
2. Needs Improvement Mentor:
3. Unacceptable Date:
REMOVABLE PROSTHODONTICS (Standards of Care)
1. Patient History and Treatment Plan A. An adequate history is obtained from the patient and required medical and dental consultations have been obtained. All necessary radiographs are present and diagnostic.
B. The patient's medical conditions and past dental history will be considered in the treatment plan and the plan based on sound prosthodontic procedures. The resident will have discussed options and possible complications. The patient should be in agreement with the plan and the time table to complete it.
2. Diagnostic Casts Casts will be accurate, bubble-free reproductions of the required structures and properly articulated when required. Casts will be surveyed and a tentative removable partial denture design drawn on the lab prescription form. The final design will be approved by a mentor.
3. Preparations Rest preparations and tooth modifications should be carried out with sound prosthodontic principles in mind, following the proposed design. The amount of tooth structure removed should provide for the desired support, retention, and stabilization of the removable partial denture or overdenture as well as proper thickness for development of occlusion and esthetics. Preparations should be checked by the mentor before final impressions.
4. Final Impressions The final impression must include all the desired anatomical structures needed in the construction of the prosthesis and must be accurate and distortion free. Border extensions and tissue pressure should be in accordance with the impression technique used.
5. Final Casts All final casts must be neat and free of bubbles and voids with land areas smoothed. The RPD master cast will be properly tripoded and borders of the desired major connectors may be marked. Prescription forms with neat, legible removable partial denture designs and instructions will be countersigned by a prosthodontic mentor prior to being sent to the laboratory.
6. RPD Framework Try-In The completed framework should be evaluated prior to the try-in. The framework must completely seat without rocking. The fit of all components, the retention, and the occlusion must be verified in the mouth.
7. Centric Jaw Relation Records
Record bases must be accurate and stable. Jaw relation records must accurately record the appropriate centric position at the proper occlusal vertical dimension. An appropriate material should be used and the record must be reproducible. A facebow will be used. Acceptable anterior and posterior shades and molds should be selected and included with the design and other necessary information on the prescription form.
8. Wax Try-In The correct centric relation position, occlusal vertical dimension, lip support, mid line, occlusal plane and phonetics should be verified. The size, shape, shade, and arrangement of the anterior teeth should be accepted by the patient and the doctor.
9. Insertion All acrylic surfaces must be free of sharp projections or edges. Tissue bearing surfaces must be evaluated with Pressure Indicator Paste and the proper border extensions verified. The occlusion should provide uniform contacts in excursive movements and the principles of a definite occlusal scheme should be identifiable. The cameo surface of the prosthesis should be properly contoured and highly polished.
10. Home Care Instructions and Post Insertion Care The patient must be given the appropriate wearing, care, and cleaning instructions. Adequate follow-up appointments must be scheduled to verify the fit, occlusion, and the patient's management of the prosthesis.
11. Laboratory Relines/Rebases; Corrected Casts An accurate impression must be made at the proper occlusal vertical dimension. The framework must be completely seated.
12. Patient Management
All patients must be treated in accordance with the highest professional standards.
13. Time Management All clinical procedures should be preplanned, discussed, and approved by the mentor. Residents should arrive on time, begin treatment promptly, and complete treatment in an expeditious manner. All laboratory procedures should be accomplished to allow the laboratory technicians ample time to meet the delivery date.
14. Laboratory Procedures Impression trays should be smooth and extended in accordance with the technique being used. The record base should be free of all sharp edges and must be accurate and stable. The tooth set-up must be in accordance with the principles of the occlusal scheme being used. The processed prosthesis should be dense and have no more than 1.5 to 2mm pin opening at the lab remount. The finished prosthesis should be highly polished with no sharp edges, blebs, or flash.
15. Standards of Care All patients will be evaluated using the appropriate standards of care form.
REMOVABLE PARTIAL DENTURES STANDARDS OF CARE EVALUATION FORM Resident Procedure
1. Medical-Dental History and Treatment Plan A thorough and complete medical and dental history is obtained from the patient and the patient's dental record to include required medical and/or dental consultation. Any medical or dental conditions are considered in the treatment plan. The prosthodontic resident should be technically capable of diagnosing and completing the conservative treatment plan with staff supervision. The patient is in agreement with the plan and understands the time required to complete it.
2. Diagnostic Casts Are accurate, clean, bubble-free reproductions of the existing dental anatomy. Casts should be properly articulated on an appropriate articulator when indicated.
3. Jaw Relation Records The resident is capable of performing proper patient jaw manipulations in order to capture appropriate centric relation/occlusion positions. Records should accurately reproduce centric relation/occlusion when working casts are articulated. Records should be of an appropriate material to allow handling by laboratory personnel without severe distortion or fracture.
4. Laboratory Procedures Working casts should be trimmed, smoothed, and free of all bubbles and voids. Land areas of working casts should be trimmed and rounded. The resident should be capable of fabricating stabilizing (flat plane) occlusal splints, soft splints, and anterior jigs.
5. Prescription Forms All laboratory prescription forms should be completed. All prescription forms going to the lab must be countersigned by a Prosthodontic mentor. Prescriptions for medications will be monitored by the staff.
6. Occlusion All devices should restore the proper occlusal plane of the patient to restore VDO, protect the TMJ, or reduce myofacial pain. This may include recontouring of opposing dentition or splints. All devices should contact in centric relation occlusion or maximum intercuspation to hold shim stock (8mm) firmly. Devices should be free of lateral interferences in accordance with the patient's occlusal scheme, i.e., canine disclusion, group function, etc.
7. Delivery All devices should be smoothed and polished to be irritation free. Devices should be retentive with no movement during functional and para-functional excursions. Residents should provide the patient with instructions as to nature, usage, and care of all devices.
8. Follow-up Residents should provide timely post-insertion visits for patients under splint therapy. All devices should be thoroughly inspected and evaluated as to their effectiveness and any needed adjustments made at this time.
9. Patient Management All patients should be treated in accordance with the highest professional standards. Derogatory comments or negative comments will not be made. Any questions concerning patient treatment should be discussed in private with the appropriate mentor.
10. Time Management Residents should preplan all conservative TMD treatment. Residents should arrive on time, begin treatment promptly, and complete treatment in an expeditious manner. All laboratory procedures should be accomplished to allow the laboratory technicians ample time to meet the delivery date.
11. Standards of Care All patients will be evaluated utilizing the appropriate standard of care form.