Assessing the Quality of Clinical

Procedures and Technical

Standards of Dental Laboratories Zakereyya S. M. Albashaireh, BDS, MSc, PblT
in Fixed Partial Denture Therapy Abdulrbman S. Ainegrisb, BDS, à

Purpose: This study was conducted to assess the quality of impressions and tooth
preparations serif to dental laboratories in iordan and tu determine the technical capabilities
of these laboratoriei fo construct fixed partial dentures. Materials and Methods: A sample of
I3& impressions and slone casts were examined for clinical errors in 35 laboratories that
construct fixed partial dentures. They were sorted into unusable, unsatisfactory, acceptable,
or satisfactory categories. The type of impression material and tray, opposing arch
impressions, and occlusal records were noted, instructions to technicians were assessed for
completeness and clarity. Information regarding laboratory slaff and equipment were
collected. Results: Half of fhe specimens inspected were categorized as unusable or
unsatisfactory; these were found in commercial laboratories. They showed at least one
clinical error such as drags or indefinite finishing lines in impressions and inadequate
reduction, undercuts, ot obvious taper on stone casts, Alginate impression material was
used for 65% of the cases. Only 27% of specimens were accompanied with instructions; of
these 22% were graded poor. No occlusal records were available with 54% of the
specimens and no articuiafors were used except in dental school laboratories. The dental
schools and some commercial laboratories had the best staff and equipment and were more
capable of fabricating fixed partial dentures than Ihose of the Ministry of hHealth and the
Royal Medical Services. Conclusion: The quality of abutment preparation and impressions
were unsatisfactory or unusable in 50% of cases. Of the 37 available instructions 8 were not
clear. The dental schools and some commercial laboratories were technically capable of
producing good quality fixed partial dentures. Int J Prosfhodont 1999;! 2:236-241.

A s more patients demand fixed partial dentures for

the replacement of missing teeth and endure a high
cost, the quality of fixed partial denture therapy be-
to patients in Jordan is a cause of worry for professionals
in this field. Moreover, the technical standards of fixed
prostheses constructed in the Ministry of Health
comes of increasing professional and public concern,^ (MOH), the Royal Medical Services (RMS), commer-
Likewise, the quality of fixed prosthodontics provided cial laboratories, and, to a lesser extent, in dental
school laboratories are thought to be disappointing.
A fixed partial denture of good quality should be
'Assistant Professor and Consultant in Conservative Dsntistry,
well designed and constructed. It should restore the
faculty af Dentistry, Jordan University of Science and Technology,
irbid, ¡ordan. function and promote the health of the masticatory
unit and provide a long service life. These criteria are
''Specialist in Conservative Dentistry, Royal Medical Seri/ices; and
Clinical Supervisor in Conservative Dentistry, Faculty of Dentistry,
influenced by the quality of clinical procedures, the
Iordan Uniyersity of Science and Technology, Irbid, Jordan. standards of the laboratory work, and the oral con-
Reprint requests: Or Z. S. M. Albashaireh, Riyadh Dental Center, ditions prevailing in the patient.' Inadequate reduc-
Fast Office Box ! 584, Riyadh ! 1441, Kingdom of Saudi Arabia. tion or imprecise preparation of abutment teeth.

The International iourral of Proslhodontii 236 Volume 12, NumbE ' "
 AI baîhai reh/AI negri sh
particularly the finishing lines, may have a profound
effect on the subsequent fit of the restoration.-
However, abutments that have been prepared and fin-
ished carefully require an equally careful and correct
impression technique using reliable materials and
suitable trays. Without this tbe impression stage can
nullify earlier achievements in the preparation.'
Provided that the initial tooth preparation and im-
pression techniques are adequate, the esthetics and
strength of a fixed partial denture are determined by
the skill of the individual technician.-" A proficient
technician may be able to correct or mask minor
faults in a preparation and produce a reasonable
restoration. Technicians should be provided with a
complete and clear prescription of the design and de-
tails ofeach restoration or component. Moreover, oc-
ciusal records should be supplied when applicable.'
Despite the importance of this broad range of fac-
tors, the inferior quality of dental prostheses has been
attributed largely to errors incurred in laboratories.^'"
The technical quality of fixed prosthodontic work
might be compromised in laboratories where old
types of equipment and inexperienced staff are in-
volved In the construction of fixed partial dentures.'
Metal-ceramic fixed partial dentures have been stud-
ied and various technical errors were reported.'
Proximal contacts were overbuilt at 65% of the sites
studied, pontic tissue contacts were excessive in the
majority of cases, and poor-qualityalloys were used.
Comparatively, a few studies have been carried out
to determine the quality of clinical procedures un-
dertaken by dentists. Impressions for anterior crowns'
and fixed partial dentures^' made in general dental
praaice have been assessed. Over half of the crown
impressions exhibited major faults and were recorded
to be unacceptable.^ Most (72%) fixed partial denture
impressions were taken with flexible plastic trays
and 36% showed defects in the recording of the pre-
pared teeth."
Few investigations have been designed to examine
the quality of clinical procedures and to determine the
capability of dental laboratories that deal with fixed
partial denture technology. Therefore, a sample of
dental laboratories was surveyed to: (/) determine the
quality of abutment preparation, impression tech-
niques, and accompanying design prescriptions of
impressions and/or stone casts; and (2) ascertain the
technical capabilities and standards of these labora-
tories to competently construct fixed partial dentures.
Materials and Methods
A sample of 60 (75%) dental laboratories, which
represented the major cities In Jordan, was randomly
selected from the Register of Dental Laboratories.
:._. ~ = L - . .-..:,....•.'2, Number 3,1999
Quality of Laboratory- Procedures for Fixed Partial Dentures
They were located as follows: 5 in dental schools, 11
in the MOH, 5 in the RMS, and 39 commercial lab-
oratories. A questionnaire was formed following a
small pilot study prior to this survey. It included
questions related to the qualifications, number, and
experience of the laboratory staff, and to the equip-
ment and techniques used during laboratory proce-
dures. Space was provided for comments regarding
fees, costs of fixed partial dentures, and training of
technicians. The laboratories selected were visited
without prior appointment and the chief technicians
were inten,'iewed and asked to complete the ques-
tionnaire during the meeting. They were given a list
of laboratory equipment and asked to indicate if this
equipment was present and used in their laboratories.
As technicians were not required to be registered, a
person was considered a technician for the purposes
of this study if they were so recognized by the labo-
ratory owner.
In each commercial and dental school laboratory
4 specimens of impressions and stone casts were ex-
amined. According to availability, 2 impressions per
laboratory were inspected in the MOH and RMS.
Specimens were inspected for defects using magni-
fication loupes (2x) and were categorized by the
same examiner according to the following criteria.
1. Unusable impressions: impressions that displayed
obvious drags, were detached from the impression
tray, and showed indefinite and interrupted fin-
ishing lines around the circumference of the
preparation.
2. Unsatisfactory casts: the prepared abutments
caused occiusal interferences on pink wax placed
between the maxillary and mandibular casts in in-
tercuspai position, displayed visual undercuts, or
demonstrated an i ncreased degree of taper,
3. Acceptable: minor modifications of inspected im-
pressions or stone casts were required, such as
cleaning blood stains from impressions, blocking
minor undercuts, and filling small air bubbles
with stone cast material.
4. Satisfactory: the impressions or stone casts were
free of any of the above errors.
Factors like the type of impression material and l:ray,
available occiusal records, and opposing arch im-
pressions of the cases selected were noted. The ex-
aminer and tbe chief technician assessed details of the
practitioner's instruction to technicians and consid-
ered them satisfactory if sufficient, clear instructions
were given and poor if a telephone call to the dental
practice was required for further information (eg, the
shade details) before the case could be started. The
results were analyzed using the Chi-squared test.
Ttie International journal of Prosthodonticî
237
 Quality of Laboratory Procedures for Fixed Partial Dentures Albasliaireh/Alnegrish

Table 1 Number (n) and Percentage ot Surveyed

Laboratories that Construot Fixed Partial Dentures
Location Total n %
School 5 4 80
Commercial 39 29 74
MOH 11 1 9
RMS 5 1 20
Total 60 35 53

Table 2 Number (n) and Peroentage of Cases Inspected According to the Factors
Studied and Laboratory Location
Institutions' Commercial Total

n n % n %

Case category
Unusable 0 0 32 28 32 24
Unsatisfactory 0 0 36 31 36 26
Acceptable 6 30 16 14 22 16
Satisfactory U 70 32 28 46 34
Total 20 100 116 100 136 100
Impression material
Alginate 2 10 87 75 89 65
Elastomeric IB 90 29 25 47 35
Total 20 100 116 TOO 136 100
Impression tray
Rigid plastic 16 80 88 76 104 76
Metal 4 20 28 24 32 24
Total 20 100 116 100 136 100
InstruGlions
Available 17 85 20 17 37 27
Mot available 3 15 96 83 99 73
Total 20 100 116 100 136 100
Poor ot available 1 6 7 35 8 22
Opposing impressions
Available 16 80 74 64 90 66
Not available 4 20 42 36 46 34
Total 20 100 116 100 136 100
Occlusal records
Available 16 80 47 41 63 46
Not available 4 20 69 59 73 54
Total 20 100 116 100 136 100
'Institutions include school MOH. arid RMS ia bo rato ries

Results A total of 132 impressions and stone casts were ex-

Of the 60 laboratories surveyed 35 (53%] were found
to be involved in fixed prosthodontics. The majority of
commercial and dental school laboratories also con-
structed fixed partial dentures. In contrast, one MOH
laboratory and one RMS laboratory did so ¡Table 1 ).
Impressions and Instructions
The distribution of cases inspected according to the fac-
tors studied and laboratory location is given in Table
2. The data on MOH, RMS, and dental school labo-
ratories were pooled and shown under "institutions."
Oniy 4 impressions were available for inspection in
the 2 MOH and RMS laboratories (2 impressions each).
amined in the 33 dental school and commercial lab-
oratories (4 specimens each). Consequently, 136 spec-
imens were examined in the 35 laboratories involved
in fixed prosthodontics. Half of these cases showed
clinical errors and were categorized as unusable and
unsatisfactory; the other half of the cases were distrib-
uted under the acceptable and satisfactory categories.
Details of the clinical errors are shown in Table 3.
All of the unusable impressions and unsatisfactory
stone casts were found in commercial laboratories. In
contrast, the cases inspected in institutionalized den-
tal schools, MOH, and RMS laboratories were of ac-
ceptable or satisfactory quality. No statistical differ-
ences were found among laboratories in relation to
case category (P > 0.05). Alginate was used for most

Tfie internationai Journal of Pro5thoclonti< Volume 12, Numbe

238
 AI basha i reVAl negrish Quality of Laboratory Procedures for Fixed Partial Demure

Table 3 Number (n) and Percentage of Clinical

EiTors in Impressions and Stone Casts
Clinical errors n
Impressions
Drag 10 15
Detached from tray 17 25
Indefinite finishing line 5 7
Stone casts
Over reduction 12 18
Undercut 9 13
Increased degree of taper 8 12
Indefinite finishing line 7 10
Total 68 100

Table 4 Percentages and Locations of Laboratories Using Listed Equipment

Type of equipment Schools (n = 5¡ Ccmmereial (n =39) f^OH(n = i i ) RMS(n =
Metal work
Surveyor 60 49 g 0
Vacuum mixer 100 62 9 20
Gas fumace 20 67 100 100
Electric fumace 100 51 27 20
Sand blaster 100 85 90 40
Casting machines
Centrifugal electric muffle 100 51 0 0
Pressure vacuum casting 100 39 g 0
Porcelain furnace
Vacuum fired 0 31 9 20
Vacuum automatic 80 44 0 0
Other equipment
Die-locating device 60 36 0 0
Ultrasonic cleaner 100 87 36 40
Bench magnifying glass 80 26 0 0
Electric welder 40 10 27 60
Dust extractor unit 100 92 27 40
Compressed air to eacti unit 100 95 44 100
ArticLlators 60 ie 0 0
Fume cupboard 100 90 82 100

cases, while a type of elastomeric impression mater-
ial was used for the rest. Plastic impression trays of a
rigid design (Solo disposable impression trays,
Cordent) were employed for the majority of cases in-
spected and metal trays were used for the remainder.
The majority of cases were not accompanied by in-
struction sheets, and 22% ofthe available sheets were
graded poor and required a telephone call to the den-
tal practice for clarification. A total of 90 opposing
arch impressions were available; occlusal records
were provided with 53 (70%) ofthem (Table 2).
laboratory Equipment and Techniques
equipment required for the fabrication of fixed par-
tial denture work. The majority of the MOH and
RMS laboratories had equipment suitable for the
construction of removable prosthodontic and ortho-
dontic appliances, butwerepoody equipped to pro-
duce any form of porcelain work (Tabie 4].
Articulators of semiadjustable type were commonly
used in the laboratories of the dental schools and
were available, but rarely used, in some commercial
laboratories. Nonprecious alloys were used exten-
sively in all iaboratoriesbecauseoftheir low cost. The
fee charged per unit varied from one laboratory to an-
other and was reputation- rather than cost-dependent.

Dental school laboratories were well equipped and Staffing

capable of performing the widest range of dental
work. They had modern types of equipment such as
pressure-vacuum casting machines, programmed
vacuum furnaces, and die-locating devices. A num-
ber of commercial laboratories possessed the basic
The total number of technicians was 183; 50 of these
employees (27%) had no dental technology qualifi-
cations. Laboratory owners considered 22 of the un-
qualified persons technicians and dealt with the

The Inlernatiorial loumäl of Prosthodontics

^ • - I r - - ; -.X Number 3,1999 239
 Quality of laboratory Procedures for Fixed Partial Dentures
remaining 28 persons as laboratory assistants. All tech-
nicians were employed on a full-time basis, and the
technician per laboratory ratios for commercial, MOH,
dental school, and RMS laboratories were 2.44, 2.36,
2.6, and 5.4, respectively. The 28 laboratory assis-
tants were excluded when these ratios were calculated.
The technicians' experience varied from 1 to 25
years, with most being either "juniors" (34%) with 1
to 5 years of experience, or "seniors" (34%) who had
worked in the field for more than 15 years. The ex-
perience of 22% of the technicians ranged from 5 to
10 years, while the remaining 10% had 10 to 15
years of experience.
Technician Comments
The chief technicians thought that the 2-year, full-time
training courses at the colleges of dental technology
were insufficient. They believed that the inferior qual-
ity of the products could be attributed in part to their
iow salaries, lack of incentives, and inaccurate clini-
cal procedures. They gave the following suggestions
as to how the clinical standards could be raised:
• Abutment teeth should be carefully prepared.
• Impressions should be taken using standard trays
and materials.
• Instructions to technicians, including design and
shade details, should be provided and written
clearly.
Discussion
The sample was randomly selected and represented
the major cities of Jordan. The questionnaires were
completed by the chief technician and were col-
lected on the day of the visit to the laboratory. This
method avoided any problems related to the mailing
system and overcame the issue of no response.
Consequently, data on 60 (75%) of the 80 registered
dental laboratories at the time of this study were col-
lected and a 100% response rate was achieved. This
is more than some of the response rates recorded in
the literature.^''"''^ Moreover, this procedure ensured
that the responses ofthe chief technicians themselves
were obtained and eliminated any possible interfer-
ence from laboratory owners.
Most dentists using commercial laboratories per-
formed unsatisfactory tooth preparation and sent un-
usable impressions. The majority of impressions were
taken with alginate; some impressions were detached
from the trays and showed obvious shrinkage.
Moreover, in half of the specimens inspected prepa-
ration features were inadequate and the finishing lines
were indistinct. These results are in agreement with
The International lournal oí Prostliodontii:
Albashaireh/Alnegrish
other reports^'' ' and with the comments of the tech-
nicians, who thought that some of the preparation and
impression procedures were inappropriate. Fine details
ofthe preparation and surrounding soft tissues can be
recorded accurately when a suitable elastomeric ma-
terial is used. Clinical procedures of such low quality
can only lead to guesswork on the part of the techni-
cian and must result in a restoration that will be com-
promised from the outset. Even a skillful and experi-
enced technician would fail to produce a restoration
of acceptable strength, biologic compatibility, and es-
thetics from an impression with such errors.^ '
Many authors have reported the importance of
using a rigid impression tray.^''^"^^ Although the rigid
plastic trays that were used are better than flexible
types, special or metal trays are recommended,^-^'
The latter are significantly more rigid, can be reused,
and are therefore a more satisfactory alternative in
terms of both cost and accuracy.
Some of the impressions were pulling away from
the tray, a finding that is in agreement with previous
studies.^'^'^''^ Such impressions can only lead to dis-
torted working dies and ill-fitting restorations,^ An ad-
hesive should be applied to the tray and the manu-
facturer's instructions should be adhered to while
manipulating impression materials.'^
Dentists supplied no prescriptions of the work re-
quested in the majority of cases. This is in agreement
with similar studies.''^' ' It seems that a standardized
prescription form, which is used in the dental schools,
may contribute to solving this problem. Some dentists
relied on technicians to relate casts in proper occlu-
sion and sent no occiusai records. These findings are
in accordance with another report." Many practi-
tioners fail to understand that a "high" restoration is
not a result of error by the technician but of defective
recording of the occlusa! surfaces of unprepared
teeth. One air bubble is sufficient to alter the articu-
lation and result in a faulty restoration.^
The dental schooi and some commercial laborato-
ries had modern types of equipment and were capable
of producing ali kindsof dentai work. In contrast, those
of the MOH and the RMS were mostly equipped for
fabricating removable acryiic dentures, orthodontic
appiiances, and some porceiain work. The 2 iabora-
tories that constructed fixed partiai dentures seemed to
be incapable of providing restorations on a large scaie.
They were still using oid types of furnaces for porce-
lain work and gas furnaces for beating casting rings.
Laboratory owners empioyed technicians of known
inadequate training and paid them iower saiaries.
Moreover, they empioyed iaboratory assistants pre-
sumabiy to perform routine tasks and gênerai work
such as cieaning, cierking, and delivering the finished
work to ciinics. The construction of a good-quaiity
240 Volume 12, Numbe'i
 Albashaireh/Alnegrish
fixed partial denture needs all the expertise and care
of a well-trained and experienced technician. The
quality of work will certainly be jeopardized if the du-
ties of the laboratory assistants are extended to in-
clude coping with sophisticated types of work.^
Technicians were concerned and unhappy with
their salaries, which varied depending on the profit
of laboratory owners. The fact that no incentives
were paid for skillful technicians may have dampened
any enthusiasm for professional development. This
made an offer of a better-paid overseas job very at-
tractive to the experienced technicians.
Conclusion
This study implies the following suggestions and rec-
ommendations:
1. Clinicians should perform accurate preparation
procedures, use proper materials and trays for
taking impressions, and supply technicians with
complete, clear instructions.
2. Owners should be required to update their labo-
ratory equipment regularly, employ technicians
with adequate training and experience, and pay
them reasonable salaries.
3. Regulations including uniform fee charges per unit
and reasonable salaries for technicians should be
applied to control the establishment of new labo-
ratories and improve the standards of existing ones.
Technology courses should be revised and the train-
ing period extended. Refresher courses for qualified
technicians should be organized regularly.
Half of the fixed partial denture cases inspected
were of unacceptable quality; these were found in
commercial laboratories. Dentists using institution-
alized dental school, MOH, and RMS laboratories
performed satisfactory clinical procedures and sent
acceptable impressions. The dental schools and some
commercial laboratories had the staff and equipment
required for producing fixed partial dentures.
.2, Number 3, 1999
Quality of Laboratory Procedures for Fised Partial Dentures
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