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Direct Preparation and Restoration Competency -
SUMMATIVE
Summative Exam Number #1 11/26/2019
Is this a Portfolio-style exam? No 11/26/2019
Patient chart number (see bottom of screen) 1168390 11/26/2019
Evaluator 1 - enter Faculty ID# 260 11/26/2019
Evaluator 2 - enter Faculty ID# 612 11/26/2019
Tie-breaking Evaluator ID# (only if required)
Tooth number
12 Yes 11/26/2019
Surfaces
Occlusal Yes 11/26/2019
Distal Yes 11/26/2019
Material Composite 11/26/2019
Preparation Details (Describe)
Section 2: Preparation
** Caries Removal Moderate, Clinically Acceptable Deviations 11/26/2019
** Outline Form/Bevel Meets All Accepted Criteria 11/26/2019
** Depth/Internal Form Slight Deviations from Optimal - Minimal Impact 11/26/2019
** Refinement Slight Deviations from Optimal - Minimal Impact 11/26/2019
** Extension/Pulpal Protection Meets All Accepted Criteria 11/26/2019
Section 3: Restoration
** Proximal Contacts(s) Meets All Accepted Criteria 11/26/2019
** Marginal Integrity Meets All Accepted Criteria 11/26/2019
** Contour/Anatomy Meets All Accepted Criteria 11/26/2019
** Occlusion Meets All Accepted Criteria 11/26/2019
** Finish/Polish/Surface Quality Meets All Accepted Criteria 11/26/2019
** Tissue Preservation Meets All Accepted Criteria 11/26/2019
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