Department of General Dentistry Division of Removable Prosthodontics Summative Evaluations For Competency #9 Rev. February 2010 Ronni A. Schnell, D.M.D., M.A.G.D.
General Guidelines for the Removable Prosthodontics Summative Evaluation 1. The format for summative evaluation will essentially divide the fabrication of a complete set of upper and lower dentures (CU/CL) into seven clinical visits (DMD IV and AS2). There will an additional summative for partial denture abutment preparation (DMD III will take place on mounted study casts and DMD IVand AS2 will be on a clinical patient). In addition, DMD III will perform several clinical procedures on the natural dentition. 2. These summatives may be taken at any time during your clinical years following completion of your formative training and qualifying steps (minimum 2 formative sessions). 3. Each summative is a separate exam in and of itself. They may be taken in any order when you are ready and not necessarily on the same patient. 4. Each summative must be completed on your own and without direction from any instructor or dental student. Assistance may be requested, however, for mixing final impression materials, setting up facebow and maintaining a clear and clean operatory. 5. All procedures must be completed within the allotted appointment time. Failure to complete the planned procedure within the scheduled time will result in an incomplete grade and the summative evaluation will need to be repeated. 6. You must schedule the appropriate amount of time for each procedure one appointment slot for each. 7. Upon planning to take a summative; you must be signed up with an instructor at the beginning of the clinical session. The patient should be presented to the instructor with all pertinent medical and dental histories and the procedure begun within twenty minutes for maximum use of your time to effect completion. 8. Presentation of your patient and commencement of the summative evaluation assumes that you and your operatory are completely prepared with the proper set up, instrumentation and infection control precautions for that procedure. Not being ready with the appropriate armamentarium will only waste valuable chairtime for you and your patient. Your instructor has the right to terminate the summative and dismiss your patient if your set up is incomplete or proper infection control procedures are not followed. (Please refer to the Armamentarium section of Removable Prosthodontics in your Clinic Manual and your Infection Control Manual for review of proper set up and protocol). 2
This includes proper clean up and disinfection of your operatory, your materials and your instruments at the end of the session. If infection control protocol is violated, the summative will need to be repeated. And, as always, breakage of infection control protocol may result in disciplinary action. 9. At all times, the patient s existing dentures (if applicable) must be out of sight and in water. 10. Chair position - upright and with good head support. 3
Outline of Expectations for Individual Summatives 1. Preliminary Impressions DMD III- Will produce a preliminary impression, utilizing Alginate, on any dentate patient. N=Natural Dentition DMD IV & AS 2- Will produce a preliminary impression, utilizing compound, on any edentulous patient. D=Denture. a. Introduce the patient - State all pertinent medical and dental histories and current medications. Discuss proposed treatment and other consultations required. Student should be able to identify and evaluate normal and pathological radiographic findings. b. Select proper tray and material. c. Present clinically acceptable preliminary impressions. 2. Final Impressions (DMD IV & AS2) a. Custom trays must be presented for intra-oral evaluation of ample room for compound and the tray s stability before commencing with border molding. b. Border molded trays will be checked for contours, stability and retention. c. The final impression will be evaluated for retention, tissue detail material distribution and support. A periodontal probe may be used for measurement of material thickness and border support. 3. Inter-Maxillary Records DMD III- Will mount casts of a natural dentition (may have some missing teeth) in Centric Occlusion (maximum inter-cuspation) utilizing a facebow and appropriate recording medium. N=Natural Dentition. DMD IV & AS2- Will perform an inter-maxillary records visit on a completely edentulous patient (CU/CL) as described below: a. Present unaltered record bases and occlusion rims before proceeding with visit. The use of soft, pink, pre-fabricated occlusion rims will not be permitted. 4
b. Establish vertical dimension of occlusion (VDO) utilizing esthetics, phonetics and the tongue blade method. Present the tongue blade showing VDR - VDO = 2-3 mm to faculty in order to evaluate this procedure. c. Scribe midline, canine lines and high smile line on maxillary occlusion rim. d. Continue canine lines and midline onto lower rim to assist you when recording Centric Relation (CR). e. Tooth and Denture Base Shade selection- Present a correctly completed tooth order form. Be prepared to discuss your selection. 4. Trial Denture (DMD IV & AS 2) a. VDO- Will be checked again using above methods discussed in 3b. b. CR- If set up in mouth differs from set up on articulator (centric is incorrect), re-take a new CR for remount of the lower cast and correct (re-set) the occlusion. c. Excursions- No incisal or canine guidance. Occlusal scheme will be evaluated based on opposing dentition (i.e. flat or curved). d. Midline- Discuss any discrepancies with the instructor. 5. Post-Dam DMD III- May be done on any patient as long as you have an upper cast for that patient. Begin with step b below. N=Natural Dentition. DMD IV & AS 2- Must be done on an edentulous maxilla as described below: D=Denture a. Present upper record base cut back to the Anterior Vibrating Line (AVL). b. Draw the AVL and post-dam design (shape) on the cast with five compressible tissue depths indicated and marked across the heel of the final cast; one at each hamular notch, one at the midline and one half way between the midline and the hamular notches. c. Define and explain the purpose of the post-dam and demonstrate the post-dam technique intra-orally; including position and shape utilizing an indelible wood stick. 5
6. Insertion (DMD IV & AS 2) a. VDO, CR and Eccentric will again be checked using the methods described in 3b. b. All borders and tissue surfaces should be checked with the appropriate pastes; Sorenson s Paste for borders and Pressure Indicating Paste (PIP) for tissue surfaces. c. Final polish will be evaluated as well as the patient s home care instructions. 7. Post-Insertion / Adjustment (DMD IV & AS 2) a. The student will be asked to perform a patient remount procedure on their edentulous patient (CU/CL). b. The student will be evaluated based upon their diagnostic ability and problem resolution (S.O.A.P.). 8. Abutment Preparation DMD III a. May be done on any dentate or partially edentulous model set (upper and lower)- in order to check for occlusal clearance. N=Natural dentition b. Present your models and a surveyor to the instructor for analysis. The instructor will survey and tripod your models and identify the teeth that will require rest seats (cingulum and occlusal) and tooth modification (guide planes, survey lines and/or undercut dimples at that path. c. Prepare the models in the presence of your instructor. d. Return the prepared models to your instructor for summative evaluation. DMD IV AND AS 2 a. Shall be done on any CLINICAL PATIENT RECEIVING A PARTIAL DENTURE. 6
Summative Exams on Team Patients The Summative Exam may be taken on a team denture patient as long as the following criteria are met: 1. Preliminary and Final Impressions- Each impression must be made on one complete arch per team member. Each team member must work independently of the other and in consecutive not simultaneous fashion. 2. Inter maxillary records- In order for both team members to receive credit for this step, each student will fabricate their OWN complete set of record bases and occlusion rims on the original final casts or their duplicates. Each student will adjust their OWN C/U C/L wax rims chairside as specified in the Practical Exam Guidelines handout. The B set does not take the records from the A set as with a conventional team denture visit, but rather obtain their own chairside records. Permission from the patient MUST be secured, as each student must complete this visit SEPARATE from the other. Only one student may treat the patient and be in the operatory at a time. 3. Tooth try in- Once again, a practical may be done by each team member as long as each student sets their OWN complete set of teeth. The B set will be utilizing the substitute technique teeth as usual. Each set will be tried in separately and independently of one another. If the B set is to be tried in, the record bases and occlusion rims must be fabricated on the A final casts. Each set will be evaluated as set forth by the Guidelines handout, with the exception of the esthetics of the B set- due to the use of the technique teeth. 4. Practical credit for the Insertion visit cannot be awarded to both students as it is not possible to duplicate this visit on the patient. 5. Since steps 1-3 must be repeated for each summative (or a formative and a summative), you must request and receive express permission from your patient for the additional procedure and time involved. Under NO circumstances may a summative be performed at the expense of a formative for the team partner. 7
Additional Summative FAQ s I. Summatives on Team Dentures: 1.. You may do so easily on prelim and final impressions, since only 1 arch of impressions is needed. 2.. Intermaxillary records may be done as well, as long as it is a second set of fresh record bases and occlusal rims not previously adjusted - AND you have taken the patient s permission to do this procedure twice. 3.. The same restriction holds true for tooth try-in. You must set up and try in the B teeth. Therefore, esthetics may not be optimal. (Although we did one the other day and the patient actually liked the B teeth better than the A teeth!) You may NOT process the B set. 4.. The Pt remount / adjustment summative may be done by both students at separate visits, as long as it is on different days. 5.. The students will have to chose who gets the insertion summative as it can only be done once. 6.. A summative many not be done at the expense of the other student s formative session, therefore it would have to be repeated. II. Single arch complete denture cases can ALSO use for summatives as the purpose is to be able to determine and manage VDO and CR. Many times, developing denture occlusion opposing natural occlusion can be challenging enough, testing that set of skills. III. Immediate denture insertion summatives can ONLY be done at the discretion of the clinical floor faculty. Only a few remaining teeth on each arch to be extracted are recommended. It is important that clinical judgment is used. A full mouth extraction case is not appropriate nor is a medically compromised patient. You must discuss your case with the faculty member ahead of time and receive written and explicit permission in the patient s chart from that faculty. If you will not be presenting at rounds it will only be because you are with your patient in Oral Surgery. One additional caveat; if this procedure becomes harmful in any way to the patient s well being, your faculty will intercede and stop the summative and suggest you re-try on a conventional case. IV. An insertion summative on a partial denture may be possible if the occlusion on the partial is denture rules and not natural rules and only with the express permission of Dr. Schnell after mounted diagnostic casts and patient chart are presented. 8
ADDENDUM DMD III (2012) Just a reminder regarding your Summative Evaluation: The purpose of the Summative Evaluation at this stage is to test something that everyone should be required to know at this stage of patient care and that everyone should have easy access to. 1. There are 4 tests: a. Alginate Impression b. Mounting c. Rest preps d. Post dam 2. Each test requires 2 qualifiers 3. ANY patient can be used, with or without teeth (even a classmate). 4. The deadline for all tests is Dec 15, 2010 In its simplest form... You make upper & lower alginates on one patient who has teeth (=2 qualifiers)... You pour up the impressions in stone... On the upper you locate the post dam & score it into the cast... On the lower, you cut some rests & do it all with an instructor (=1 qualifier each)... You mount the upper using a facebow and mount the lower in CO (=1 qualifier each)... If you are planning to diagnose & treatment plan ANY of your assigned patients, you should AT MINIMUM, make diagnostic casts & mountings. The other tests... the rest preps & post dam, are easily added since MOST of your patients have teeth and ALL of them have ANTERIOR VIBRATING LINES. 9