VII. Standards to Assess Outcomes

Fixed Prosthodontics

(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.

Fixed Prosthodontics Standards of Care Evaluation Form

Removable Prosthodontics

(Standards of Care)

1. Patient History and Treatment Plan

1. An adequate history is obtained from the patient and required medical and dental consultations have been obtained. All necessary radiographs are present and diagnostic.
2. 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

Complete Dentures Standards of Care Evaluation Form

Temporomandibular Disorders

(Standards of Care)

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.

Temporomandibular Disorders Standards of Care Evaluation Form

Maxillofacial Prosthodontics

(Standards of Care)

1. Medical-Dental History and Treatment Plan

A thorough and complete medical and dental history is obtained from the patient to include the pathology report and radiation/oncology report where indicated. Any medical or dental conditions such as radiation or chemotherapy are then considered in the treatment plan. The prosthodontic resident should be technically capable of completing the 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 and/or facial anatomy. Casts should be properly articulated on an appropriate articulator when indicated.

3. Jaw Relations Records

The resident is capable of performing proper patient jaw manipulations in order to reflect correct relations. Records should be of an appropriate material to allow handling by laboratory personnel without severe distortion.

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.

5. Prescription Forms

All laboratory prescription forms should be completed. All prescription forms going to the lab must be countersigned by the maxillofacial prosthodontist.

6. Devices

All devices should restore the proper function and esthetics of the patient. This may include proper velopharyngeal function, mastication, swallowing, speech, or obturation.

7. Delivery

All prostheses should be smoothed and polished to be irritation free. Prostheses should be retentive with no movement during function, if possible. Residents should provide the patient with instruction as to the nature, usage, and care of all prostheses.

8. Follow-Up

Residents should provide timely post-insertion visits for patients under therapy. All prostheses 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.

10. Time Management

Residents should preplan all maxillofacial 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 standard of care forms.

Maxillofacial Prosthodontics Standards of Care Evaluation Form

Implant Surgical Placement

(Standards of Care)

1. Review patient's Medical & Dental History and medication Interaction

A thorough medical and dental history is obtained from the patient's dental record to include required medical and/or dental consultations with Periodontics, Endodontics, Oral Surgery, Oral Medicine, Orthodontics.

Review of medical conditions that could make a patient unsuitable for implant treatment or could complicate surgery

Resident should be able to determinate patient’s medication interactions and need for medical consultation.

2. Diagnostic Articulated Casts

Accurate, clean, bubble-free reproductions of the existing dental anatomy and surrounded soft tissue should be fabricated.

Two sets of diagnostic casts, one set as pre-treatment record and a second set for diagnostic wax-up should be accurately articulated at the proposed vertical dimension of occlusion to reveal available mesial-distal, buccal-lingual, and interocclusal space for implant placement.

3. Diagnostic Waxing and Radiographic/surgical Guide

Guides should indicate the desired location and inclination of implants during placement. Radiographic guides will be fabricated for every patient. For overdenture or hybrid prostheses, dentures will be fabricated to the wax stage to determine proper location of implants, type of abutments for stage 2, and ultimately the type of retention mechanism, i.e.: precision attachments, locator, ERA, etc. A surgical guide will be made based on this information. For partially edentulous prostheses, a complete waxing will be completed to determine contours of the final prosthesis, type of prosthesis to be fabricated, i.e.: cemented vs. screw retained, type of abutment for stage 2, etc.: Final position of implants will be based on these decisions. A surgical guide will be fabricated based on this information using conventional guide methods or Nobel Biocare guided surgery methods as needed. Digital technology is to be used when applicable and advantageous to the patient.

4. Diagnostic imaging

Distortion-free intraoral radiographs should be taken. Appropriate imaging of the mandible and the maxilla, and interpret the findings to inform treatment.

Use of cone beam CT is required and should be read with a help of planning software.

Evaluate surgical anatomy and/or pathological process of the maxilla, the mandible and the surrounding tissues.

Accurately identify location of vital structures: i.e. maxillary sinus, mandibular inferior alveolar canal, mental foramen, incisive canal.

Evaluate quality, quantity and morphology of the bone in possible implant sites.

5. Treatment Plan & Implant selection

Upon presentation of photographs, articulated cast, diagnosis waxing and cone beam CT, a plan based on sound surgical and prosthodontic procedures will be formulated.

Prior to initiating therapy, a comprehensive treatment plan, including caries removal, disease control, periodontics, endodontics, etc. must be formulated. All available treatment options must have been presented to the patient prior to beginning therapy.

Know the principles and process of obtaining patient consent form prior to implant treatment: other treatment options, indications and contraindication, advantages and disadvantages.

At this point selection of surgical sites are made and surgical materials are ordered with 15 working days of anticipation. Please see Dental Implant Prosthetic Order Form and submit form to Mail Box Location-Rm.4453 to Rose Morgan at least 15 working days prior to scheduling the surgical procedure.

6. Surgical Procedure

Perform surgery following effective control of infection and principles of aseptic techniques, proper wear of surgical gowns, mask and sterilized non-latex gloves.

Proper medical management of patient, Blood Pressure must be taken at the beginning of each visit.

Practice appropriate record keeping, treatment plan consent, patient consent on day of treatment, axium notes on day of treatment.

Manage appropriate pharmaceutical agents and know interaction with existing medication/s. Understand prescription of pre-operative and post-operative medications- antibiotics,analgesics, anti-inflammatory, antihistamines/decongestants and anti-microbials, ie. Chlorhexadine gluconate oral rinse.

7. Post-Surgical Period

Understand the healing processes that normally occur following implant surgery- stage 1 vs. stage 2 procedures.

Identify early and late complications and do follow-up treatment as needed: i.e. 1 day after immediate placement, immediate loading, extraction and immediate delivery of prosthesis, 7 days after conventional implant placement.

Cover fixtures or healing abutments should be placed accordingly and if not visible clinically a final radiograph confirming seating of the abutment is needed.

8. Phase 2 – Surgery

Understand need for stage 1 or stage 2 surgical procedures. Transmucosal abutments will be placed at the appropriate time. Understand selection of mucoperiosteal flap, apical reposition flap or tissue punch for stage 2 procedures. Complete seating of the abutments to underlying fixtures must be verified radiographically, if not visible clinically.

9. Home Care Instructions

Instruct patient of surgical care, Coe-pack placement, use of reusable insulated cold pack, chlorhexidine rinse. A demonstration of the proper cleaning and care of the interim prosthesis must be given to the patient at the time of insertion. The patient should be given a follow-up appointment to evaluate and reinforce surgical care.

10. Post-Surgical Care

Following insertion of the implant placement, the patient must be seen in 1 day, 7 days or a 2 -week period depending on the type of surgery performed.

11. Standards of Care

All patients will be evaluated utilizing the appropriate standards of care forms.

Implant Prosthodontics

(Standards of Care)

1. Medical-Dental History

A thorough medical and dental history is obtained from the patient's dental record to include required medical and/or dental consultations. Any medical or dental conditions are considered in the treatment plan.

2. Diagnostic Articulated Casts and Radiographs

Accurate, clean, bubble-free reproductions of the existing dental anatomy should be fabricated. Casts should be accurately articulated at the proposed vertical dimension of occlusion to reveal available mesial-distal, buccal-lingual, and interocclusal space for implant placement. Appropriate radiographs will be available. Measuring guides will be used and potential distortions understood.

3. Treatment Plan

A plan based on sound surgical and prosthodontic procedures will be formulated. Upon approval of the mentors, a treatment plan that the resident is technically capable of completing under staff supervision can be initiated.

4. Diagnostic Waxing and Surgical Guide

Guides should indicate the desired location and inclination of implants during Phase I placement. Surgical guides will be fabricated for every patient. For overdenture or hybrid prostheses, dentures will be fabricated to the wax stage to determine proper location of implants, type of abutments for stage 2, and ultimately the type of retention mechanism, i.e.: clips, locator, ERA, etc. A surgical guide will be made based on this information. For partially edentulous prostheses, a complete waxing will be completed to determine contours of the final prosthesis, type of prosthesis to be fabricated, i.e.: cemented vs. screw retained, type of abutment for stage 2, etc.: Final position of implants will be based on these decisions. A surgical guide will be fabricated based on this information.

5. Phase I - Post Surgical Period

Existing removable partial dentures or complete dentures should be relieved, adjusted, and relined with a soft liner to accommodate tissue changes within the surgical area. Functional forces to the implants should be eliminated or minimized during the initial phase of osseointegration.

6. Phase 2 - Surgery/Preliminary Impressions

1. Transmucosal abutments will be placed at the appropriate time. Complete seating of the abutments to underlying fixtures must be verified radiographically, if not visible clinically.
2. Accurate, clean, bubble free impressions with appropriate transfer analogs should be made after abutment connection is verified.

7. Final Impression

The final impression must be an accurate representation of the implant abutments or fixtures and surrounding tissues. A verification jig will be made at the impression appointment or from the master cast to verify the accuracy of the impression on prostheses of more than one tooth.

8. Record Bases

Base plates should be stable and accurate. When completely seated, they should have intimate contact to implant analogs, with no movement. Occlusion rims must be contoured to provide proper support to lips and surrounding tissues.

9. Jaw Relation Records

Jaw relation records should be made in centric relation at the established vertical dimension. For the hybrid prosthesis, there must be at least 12mm between the maxillary incisal/occlusal plane and mandibular edentulous ridge to allow adequate space for artificial tooth placement. A facebow will be used when indicated. Acceptable shades and molds should be selected.

10. Wax Try-In

The correct centric relation position, occlusal vertical dimension, lip support, midline, occlusal plane and phonetics should be verified. The size, shape, shade, and anterior arrangement should be accepted by the patient and doctor. For a hybrid type prosthesis, the mandibular anterior teeth should be above the transmucosal abutment and gold coping connections. The extension of the posterior occlusion beyond the center of the distal abutments should be in accordance with the number, size, location/configuration of the implants.

11. Framework

The casting for the super-structure must be evaluated to verify proper cantilever length and contours. The casting should seat completely, while passive, to all abutments. If not, the framework should be separated and soldered or remade.

In the case of the partially edentulous the framework should be designed as best as possible to duplicate contours of normal anatomy. Adequate metal substructure for proper porcelain application on axial and occlusal surfaces must be present.

12. Insertion

The completed prosthesis must possess a passive, accurate fit to each abutment cylinder. A clinical remount procedure should be accomplished to eliminate occlusal interferences. All resin and metal surfaces should be highly polished without sharp projections. Access openings should be blocked out with suitable resin or composite material following final seating of the prosthesis.

13. Home Care Instructions

A demonstration of the proper cleaning and care of the implant prosthesis must be given to the patient at the time of insertion. The patient should be given a follow-up appointment to evaluate and reinforce home care.

14. Post-Insertion Care

Following insertion of the implant prosthesis, the patient must be seen every three (3) months for the first year and semi-annually thereafter for prophylaxis and recall.

15. Standards of Care

All patients will be evaluated utilizing the appropriate standards of care forms.

Implant Prosthodontics Standards of Care Evaluation Form

Implant Placement Standards of Care Evaluation Form

Advanced Specialty Educational Program in Prosthodontics

Consultant Evaluation

Resident Evaluation - Oral Presentation

End-of-Year Program Critique

Post-Graduation Critique

Dental Resident Evaluation Report

Dental Resident Evaluation Report