Does the Sequence of Preclinical Dental

Crown Type Preparations Affect Evaluation

Scores?
Tom V. Korioth, DDS, PhD; Michael A. McBride, DDS
Abstract: Preclinical dental students must demonstrate aptitude in the preparation of teeth for treatment with several types of
fixed dental prostheses. The optimal sequence of instruction and examination of these crown preparations in preclinical fixed
prosthodontics is unknown. The aim of this study was to determine if grading scores by faculty and students were affected by
changing the sequence of crown type preparations. Practical exams of two successive student cohorts (n=89 in 2014; n=92 in
2015) at one U.S. dental school using three crown preparations (full cast, porcelain fused to metal, and all-ceramic) in different
order were analyzed by faculty grades and student self-assessment. All of the models indicated that the sequence in which the
crown type preparations were taught did have an effect on the grades. The 2014 cohort had overall higher grades and particularly
higher grades for the all-ceramic crown preparations. Evaluation scores were affected by the sequence in which the different
crown type preparations were taught and tested. Although the overall results suggested that students may perform better if the
all-ceramic crown preparation is taught last, this tendency may differ between years.
Dr. Korioth is Professor and Director of Fixed Prosthodontics, Department of Prosthodontics, College of Dentistry, University of
Tennessee Health Science Center; and Dr. McBride is Associate Professor and Director of Clinical Education, Office of Clini-
cal Affairs, College of Dentistry, University of Tennessee Health Science Center. Direct correspondence to Dr. Tom V. Korioth,
Department of Prosthodontics, College of Dentistry, University of Tennessee Health Science Center, Room C-515 Dunn Bldg.,
875 Union Ave., Memphis, TN 38163; 901-448-6930; tkorioth@uthsc.edu.
Keywords: dental education, prosthodontics, crowns, fixed dental prosthesis, self-assessment
Submitted for publication 1/4/16; accepted 6/15/16

I
n preclinical fixed prosthodontics, dental students
must demonstrate proficiency when preparing
teeth to receive different crown types: full cast
crown (FCC), porcelain fused to metal (PFM), or all-
ceramic (AllCER). For practice, these preparations
are done multiple times per crown type to improve
motor skills and to develop abilities needed to pass
the fourth-year mock boards and the dental licensure
mannequin exam.1 A significant relationship has been
found between passing the mock board fixed prosth-
odontic preparation and the successful completion of
that procedure on the state licensure exam.2
Evaluation outcomes in preclinical fixed
prosthodontics have been correlated with digital tooth
preparation analysis,3 shortened preclinical exercis-
es,4 and the use of instructional videos and computer-
based simulations,5 among others. Self-assessment, in
which students rate their own performance against a
standard, has been found to contribute to active learn-
ing.1 Whereas studies have shown lack of evaluation
accuracy in self-assessment,6-8 others have reported
that self-assessment improves learning motivation
and higher achievement.9,10
The ideal sequencing of competencies in
fixed prosthodontics is still unknown. Historically,
the order of crown preparation practicals has been
based on adopted or inherited teaching methods of
established curricula. At the University of Tennessee
Health Science Center College of Dentistry (UTHSC
COD), second-year dental students take three practi-
cal examinations or competencies during their single-
unit fixed dental prostheses (FDP) course—one for
each crown type. Traditionally, students have started
out with FCC, moved on to PFM, and finished with
AllCER crowns. The sequence was changed for 2015
so that students started out with AllCER, moved on
to FCC, and ended with PFM preparations. All of the
practical exams conform to the ones taught at various
U.S. dental schools.11
The aim of our study was to determine if grad-
ing scores by faculty and students were affected by
changing the sequence of crown type preparations.
This knowledge could be used to enhance preclinical
outcomes in fixed prosthodontics by better streamlin-
ing students’ tooth preparation skills.

December 2016  ■  Journal of Dental Education 1457


Methods
The study was determined to be exempt from
oversight by the Institutional Review Board at the
University of Tennessee Health Science Center.
Past grading data on full coverage single unit FDP
preparations were collected for three independent
exams over two years. Two successive cohorts of
second-year dental students (89 students in 2014 and
92 students in 2015) were chosen for the study. The
total sample size was based on a 2 (years) x 3 (exams)
x 2 (evaluations) data matrix. Student confidentiality
was maintained.
Over the course of three months during their
second year, the students took three different practical
examinations involving the preparation of a specific
ivorine tooth on a typodont (ModuPRO Pros, Aca-
dental Inc., Overland Park, KS, USA) attached to
a mannequin (KaVo Dental, Charlotte, NC, USA).
Each of the three crown preparations (FCC, PFM,
and AllCER) was thus tested independently. Each
exam lasted two and a half hours, which included the
preparation itself plus the fabrication of an interim
FDP on the cut artificial tooth. Prior to each practical
exam, students received pertinent lectures on design
and technique as well as approximately ten to 12
hours of supervised lab instruction specific for the
preparation type. Evaluation criteria were explained
to the students before each exam in an attempt to
improve self-assessment accuracy. At the end of the
examination period, students were given 15 minutes
to grade their tooth preparation on pre-designed
evaluation sheets (available from the corresponding
author). Ratings were based on students’ ability to
cut a tooth to conform to specific dimensions.
For each exam and tooth preparation, a total
of 21 variables were evaluated. These were divided
into three groups: Clinical Perception (five variables),
Measurements (11 variables), and Provisional (five
variables). The grades were based on the Clinical
Perception and Measurements categories only, with
the latter having a larger amount of measurable
(objective) variables to improve self-assessment ac-
curacy. The students circled the deficiencies on their
evaluation sheet, with possible deductions being of
-2, -4, or -10 points for each variable in increasing
order of importance.
Two trained faculty members with previous
grading experience assessed the examinations in
random order for every event and both years. To
establish a measure of interrater reliability, five
1458
randomly chosen preparations were graded by both
examiners, yielding an inter-examiner correlation
(Pearson’s r) coefficient of 0.51. Students were
awarded final bonus points on the basis of scoring
differences: no difference or perfect grading match
was awarded with +2 additional grade points, and the
largest difference (either large under- or overgrad-
ing by students) was penalized with a deduction of
-2 from the final grade. Scoring was done without
knowledge of students’ identities.
The distribution of data was analyzed for
normality of errors of residuals. Student’s t-tests
were used to compare grading scores to determine
differences between years. A linear mixed model was
used to compare the trajectories of the grades over
the course of the semester, while accounting for the
correlation for each student and within each year.
All statistical analyses were performed using SAS/
STAT, version 9.4 (SAS Institute, Cary, NC, USA).
A difference of p≤0.01 was considered to be statisti-
cally significant.
Results
The normality of the data is shown in Figure
1 for faculty scores and Figure 2 for student evalu-
ations. The t-tests revealed a very significant dif-
ference between the two instruction years but for
all-ceramic crown scores only, both for faculty and
student assessments. For all exams, students evalu-
ated themselves higher than did the faculty (Table 1).
All of the linear mixed models (faculty and
students) that compared the trajectory or sequence of
the grades over the course of the semester indicated
that the order in which the crowns were taught did
have an effect on the students’ scores (statistical data
available from the corresponding author). The 2014
preparation grades resulted in overall higher grades
and particularly higher scores on the all-ceramic
crown exam than the 2015 scores (Figure 3 and
Figure 4).
Discussion
The optimal sequence of crown type prepara-
tions in preclinical fixed prosthodontics is unknown.
Our study addressed this by comparing the scores of
two student cohorts. Scoring grades improved over
time, regardless of crown type preparation sequence.
Students improved their grades when they started
Journal of Dental Education  ■  Volume 80, Number 12
Figure 1. Normality in distribution of errors of residuals for faculty scores, with predicted means and quantiles
with a full cast crown and ended up with an all-
ceramic FDP preparation (year 2014) or when they
started out with the all-ceramic preparation followed
with the full cast crown and ended with the porcelain
fused to metal exam. This result appeared to be true
for both faculty and student scores. However, the
scoring differences between the all-ceramic groups
were the most significant and stood out clearly from
the two other crown type preparations. Although
the first practical crown preparation exams yielded
the lowest scores for both years, possibly also due
to a lack of familiarity with the examination system
as well as practical skills, our results contradict the
reasoning of first teaching a crown preparation like
an all-ceramic one that is more “forgiving” due to
December 2016  ■  Journal of Dental Education
a higher amount of tooth structure removal when
compared to a full cast crown preparation.
Students’ self-evaluations were consistently
higher than those by the faculty members, corrobo-
rating the findings of others that indicated students’
tendency to overestimate their preclinical dental
restorative work.12-14 However, when student self-
assessments were compared with peer assessments
and faculty scores, the differences were not sig-
nificant in another study.15 A possible reason may be
inconsistent inter-examiner agreement.16-18 Another
source of variability lies in the lack of the students’
improvement in their ability to self-evaluate their
work, with poorer performing students being unable
to realistically evaluate their own projects and rating
1459
 Figure 2. Normality in distribution of errors of residuals for students’ self-evaluation scores, with predicted means and
quantiles
their skills highest and the higher performing students
rating themselves lower than anticipated.19,20
Preclinical student self-assessment in re-
storative dentistry has been analyzed in cross-
sectional12,13 and longitudinal studies.19-21 In general,
longitudinal studies have demonstrated the benefits
of self-assessment by showing improved agreement
over time in scoring between faculty and students22
and an enhancement in assessment recognition
skills.23 In this sense, Curtis et al. reported that an
improvement in student self-assessment predicted
an improvement in examination scores among dental
students who were completing a preclinical complete
removable dental prosthesis tooth setup.24
An enhancement in students’ self-assessment
could be obtained by incorporating digital software
1460
shape analysis into the curriculum.25 Although a
computer-generated scan has been found to be more
precise than the hand-graded traditional method,26 as
well as preferred by students,27 it may also lack good
correlation with conventional grading by standard-
ized faculty, possibly due to the limitation of the
grading software to include all pertinent evaluation
criteria.21 It is clear that current computer-aided sys-
tems with immediate feedback capabilities are ideal
instruments for unbiased, on-time self-assessment
in preclinical fixed prosthodontics instruction. How-
ever, it is the sequencing of instruction or exams,
even with the latest technology, that can also have a
significant impact on outcomes. The sequencing of
instruction material has been studied earlier in other
academic fields such as chemistry, mathematics, and
Journal of Dental Education  ■  Volume 80, Number 12
Table 1. Scoring statistics for 2014 and 2015 by scoring group and crown types
Scoring 2014 2015 p-value

Faculty
FCC
Mean±sd 84.3±6.5 84.4±6.9 0.88
Median (range) 86 (60-94) 84 (60-96)
PFM
Mean±sd 84.3±6.4 84.3±7.1 0.96
Median (range) 86 (60-96) 86 (62-96)
AllCER
Mean±sd 87.7±5.5 82.7±8.2 <0.001
Median (range) 88 (66-98) 84 (60-96)
Students
FCC
Mean±sd 85.3±5.5 84.6±5.0 0.40
Median (range) 86 (67-98) 84 (72-98)
PFM
Mean±sd 86.1±4.9 86.9±5.3 0.33
Median (range) 86 (70-94) 87.5 (70-98)
AllCER
Mean±sd 89.2±4.2 85.1±5.2 <0.001
Median (range) 90 (74-98) 86 (70-96)
Note: The order of preparations was full cast crown (FCC), porcelain fused to metal (PFM), all-ceramic (AllCER) in 2014 and AllCER-
FCC-PFM for 2015. The p-values were determined with Student’s t-test. Scoring was done by two faculty members in both years and by
89 students in 2014 and 92 students in 2015.

Figure 3. Faculty scores (least squares means) for all three crown preparations by year

Note: The order of preparations was full cast crown (FCC), porcelain fused to metal (PFM), all-ceramic (AllCER) in 2014 and AllCER-
FCC-PFM for 2015.

December 2016  ■  Journal of Dental Education 1461

 Figure 4. Students’ self-evaluation scores (least squares means) for all three crown preparations by year
Note: The order of preparations was full cast crown (FCC), porcelain fused to metal (PFM), all-ceramic (AllCER) in 2014 and AllCER-
FCC-PFM for 2015.
psychology. The results have shown that outcomes
were positively influenced by order in difficulty of
test questions,28 the application of cognitive load
theory by repetitive, sequential teaching to engage
more of the long-term memory,29 and the sequence
of degree in difficulty of the instruction material.30
In the case of our program at UTHSC, the
choice of FDP sequence with all-ceramic crown
preparation last is now based on a better integra-
tion with the remaining restorative curriculum,
especially due to the general tendency towards the
use of more all-ceramic materials. In this sense,
we reverted to the past sequence in which we start
preclinical fixed instruction over one academic
year with an FCC single unit FDP and end it with
multi-unit all-ceramic bridgework. This sequence
also allows for more seamless integration with our
CAD/CAM course.
One of the limitations of our study was the low
number of faculty graders. While intra-examiner
variability was not assessed, the individual teaching/
grading experience of both examiners (30+ years
combined) and published data indicate a generally
1462
lower intra- than inter-examiner variability overall.17
Ideally, a higher number and standardized training
of assessors and more objective measurement tools
could improve the reliability of the scores.31 Accord-
ing to Chambers and LaBarre, simple adjustments
to judgment scores can be made more effective than
grading checklists or faculty calibration.32 An im-
provement in inter-examiner agreement or scoring
consistency could be achieved by either increasing
the number of standardized evaluators (minimum
of three with seven needed to obtain a very strong
correlation coefficient) or dramatically simplifying
the scoring criteria.33
Conclusion
In this study, the evaluation scores were af-
fected by the sequence in which the different crown
type preparations were taught and tested. Crown
preparation grades improved significantly over time
with an increase in number of practical exams, with
the all-ceramic crown preparations resulting in the
Journal of Dental Education  ■  Volume 80, Number 12
most significant differences. Although the overall
results suggest that students may perform better if
the all-ceramic crown preparation is taught last, this
tendency may differ between years.
Acknowledgments
Our gratitude goes to Vikki Nolan, DSc, MPH,
from the Biostats, Epidemiology, and Research De-
sign Clinic at UTHSC for her professional statistical
help.
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