Prosthetics

Richard Horwitz

How Good are Our Impressions?

An Audit of Alginate Impression
Quality in the Production of
Removable Prostheses
Abstract: Impressions are taken regularly in practice giving vital information to the dental laboratory, but are there quality assurance systems in place
to make sure that they are up to a sufficient standard? As dental professionals we have to appreciate that dental technicians can only work with the
information given to them. This makes the skill of taking a good impression vital in order for us as clinicians to provide prostheses of good quality. This
paper outlines an audit of alginate impressions and their quality in the making of removable prostheses.
Clinical Relevance: To record the quality of impression taking, and how ones own ability to critique an impression may differ from that of
our colleagues.
Dent Update 2014; 41: 366369

Methodology
A prospective audit was carried
out with two cycles over a six-month period
on alginate impressions for the provision
of removable prostheses. A sample size of
10 impressions per cycle were recorded
and assessed according to the criteria
and standards set below. A data sheet
was compiled listing the purpose of the
impression, the type of tray used and the
quality score from the clinician, a peer
review score from another dentist in the
practice and the dental technician.

Criteria and standards

A protocol was established

Richard Horwitz, BDS, MFDS, RCSEd,

FHEA, General Dental Practitioner,
London, UK.

366 DentalUpdate

to provide a reproducible method for

completing an alginate impression:1,2
Choose appropriate tray, check extension
and modify where necessary;
Mix alginate rapidly with a flat spatula for
one minute;
Load tray evenly;
Inset tray and mould borders by
manipulating soft tissues;
Leave past initial set to allow for
continual cross-linking, thus improving the
elastic nature of the alginate;
To remove break seal, and remove in one
fluid movement to minimize distortion;
Rinse impression under tap for one
minute and disinfect.
Criteria and standards were
established to create a scoring system for
the impressions (Table 1).
This was based on criteria
set in three separate studies assessing
impressions quality3,4,5,6 and formulated
with input from a local dental laboratory.

This enabled the scoring system to

remain impartial. A target was set for the
standard of alginate impressions taken
in the first audit cycle. This was to take
impressions of a score above 3 and to
score a 4 or a 5 at least 50% of the time.
A sample was taken in the
first cycle of 10 alginate impressions.
Examples of impressions with their
scoring are displayed in Figure 1.

Results of first cycle

The results are displayed in
Table 2. They reveal a failure in matching
the above criteria, with some impressions
scored as a 1 and 2. An average of 43.3%
impressions were scored 4 or 5.

Discussion
The results of the first
cycle reveal that 90% of impressions
taken were a minimum standard of 3
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Prosthetics

1 Very poor
2 Poor impression 3 Satisfactory
impression
impression

4 Good
impression

5 Excellent
impression

From this
No, a satisfactory
Unlikely
Most likely, Yes
Yes, a satisfactory
impression can a prosthesis could not
prosthesis could be
satisfactory
be made
made
prosthesis be
provided?

Free of blood,
No
Yes
Yes
Yes
saliva and food
debris?

Voids, bubbles,
Major insufficiencies Major insufficiency
Minor insufficiencies Minor insufficiency
pulls or tears?
affecting the future
affecting the future
affecting the future
not directly affecting

denture-bearing area denture-bearing area denture-bearing area the flange or

abutment teeth

Yes, a satisfactory
prosthesis could be
made

Does the
No
impression capture
the oral anatomy
required?

Impression of the
Yes
sulcus insufficient.
Dentition not fully
included on impression

Yes

Yes

Be free from
distortion?

No, impressions
detached from
impression tray

Yes

Yes

No, impressions
detached from
impression tray

Yes

Yes

None present

Table 1. Scoring system to assess quality of alginate impression. Please rate the following impression 15 using the criteria given. Circle the answer that best
describes the impression. The impression has to fulfill all the requirements for an overall impression score to be granted.

Figure 1. Examples of impressions with their scoring displayed.

(satisfactory) or above when self assessed,

in comparison to 80% when assessed by
the peer review scorer and the laboratory.
This reveals that not only did the author
not meet his initial standard set, but also
his marking was more flattering than that
of the independent adjudicators. Another
finding from the results demonstrates a
higher score being given when a rigid
special tray is used for a secondary
May 2014

impression, in contrast to when a plastic

stock tray is used for primary impressions.

Implementing change
Actions taken to improve the
authors impression-taking ability came
from evidence-based research1 which
entailed a how to guide using dental
alginate. Tutorials with the DF1 trainer in

tray extension and manipulation with

green stick were helpful.
Recommendations that the
author took forward to the next audit
cycle included anticipating tray extension
on every patient to make sure impression
material is never unsupported and prone
to distortion. Also based on the authors
findings and research, metal rim lock
trays were then to be used for primary
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Prosthetics

impressions.5 As the standards were not

met on the first audit cycle, the standard
set was unchanged. One could argue
that the initial criteria may have been
set too high, however, it should not be
acceptable to score anything less than
a 3 and, therefore, it was important to
improve impression-taking skills before
performing the second cycle of audit.

Results of second cycle

The results for the second
audit cycle are displayed in Table 3. They
reveal success in matching the criteria
set with all impressions at a minimum
score of 3 and an average of 56.6%
scoring at 4 or 5. These fulfil the initial
standards set.

Reflection and
recommendations for future
audit
The results of the second
cycle indicate an overall improvement in
being able to produce an impression of
good quality.
There are aspects of the
audit which the author feels need
improvement before further cycles take
place:
When scoring the impression the
criteria were too rigid and different
criteria are needed for a primary or a
secondary impression. It would therefore
be appropriate to create a separate
scoring system dependent on the type
of impression being taken.
It is difficult to know the difference
between the grading categories with
respect to very poor, poor, good and
excellent. If an impression were good,
it would not need to be any better.
Likewise, if impressions were poor then
it would be just as unacceptable as very
poor. A simplified system may, therefore,
be appropriate.
In order to complete the cycle of
usability of impressions, it may also be
appropriate to introduce assessment of
the models as a more reliable indication
of the impression effectiveness.7
The technicians scoring were not
scoring blind, as these were the only
impressions that were being assessed.
If this audit were to be reproduced on a
May 2014

PATIENT
TYPE OF IMPRESSION TYPE OF TRAY

PRACTITIONER
SCORE

PEER REVIEW
SCORE

LAB SCORE

TT

UPPER PRIMARY

STOCK

TT

LOWER PRIMARY

STOCK

LS

UPPER PRIMARY

STOCK

TT

UPPER SECONDARY

SPECIAL TRAY

TT

LOWER SECONDARY

SPECIAL TRAY

AV

UPPER PRIMARY

STOCK

AV

UPPER PRIMARY

STOCK

LS

UPPER SECONDARY

SPECIAL TRAY

AV

UPPER SECONDARY

SPECIAL TRAY

AV

LOWER SECONDARY

SPECIAL TRAY

PATIENT
TYPE OF IMPRESSION TYPE OF TRAY

PRACTITIONER
SCORE

PEER REVIEW
SCORE

LAB SCORE

FB

UPPER PRIMARY

STOCK

FB

LOWER PRIMARY

STOCK

GH

UPPER SECONDARY

SPECIAL TRAY

JA

UPPER PRIMARY

STOCK

JA

UPPER SECONDARY

SPECIAL TRAY

LE

UPPER PRIMARY

STOCK

LE

UPPER SECONDARY

SPECIAL TRAY

AR

UPPER PRIMARY

SPECIAL TRAY

JO

UPPER PRIMARY

STOCK

RK

LOWER PRIMARY

STOCK

Table 2. Results of the first audit cycle.

Table 3. Results of the second audit cycle.

larger scale involving different practices,

a more accurate reflection on impression
quality may be provided.
Overall, the audit has provided
a significant opportunity to be both
self-reflective and self-critical, whilst
encouraging a team approach to improve
the quality of patient care.
Acknowledgements

Thank you to Professor

Andrew Eder (Eastman Dental Institute,
UCL) for his support and help with this
audit.

References
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Making a Good Impression. Dent
Update 2005; 32: 169175.
2. Walmsley AD, Perryer DG, Patel D. Are we
abusing our alginate impressions? An

audit. Dent Update 2007; 34: 650653.

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Assessing the quality of clinical
procedures and technical standards
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4. Vakay RT, Kois JC. Universal
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impressions. Compend Contin Educ
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A. The quality of impressions for
crowns and bridges received at
commercial dental laboratories. Br
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cast for construction of partial
dentures. Br Dent J 1985; 159: 45.
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