Adding anatomical accuracy

Boutique lab. I really dislike that moniker used by many to describe laboratories that deliver a more comprehensive end product than the norm.

Just 20 years ago what we now define as boutique offerings were taught and practiced as the level those fabricating fixed or removable prosthetics were aspiring to provide on a daily basis. I prefer to define those who provide above the commodity standard as Comprehensive Laboratories, rather than the mis-termed boutique.

All inclusive

Comprehensive Laboratories choose to compete with other labs by striving to provide the best results in regard to function, naturally driven esthetics and techno-clinical expertise. This is what it takes to truly deliver results worthy of being called restorative dentistry, which is the patient’s expectation. For way too long, dental laboratories have prided themselves as being able to work on anything, using any timeframe, to provide an acceptable rather than exceptional result. In our race to be competitive, by commoditizing the products we fabricate, we have redefined providing the best of what we can do as some kind of specialty.

Over the years I have found that if my business model was going to be successful in providing removable prosthetics in what is sadly defined in today’s dental technology industry as a niche, the soundest strategy was to provide services and techniques that must be learned and mastered, rather than purchased. By doing so, I eliminate about 90% of the competition who either reject the notion of the need for anything above what is considered deliverable based on either how long it takes to get a marketable result or the amount of time and difficulty it takes to implement it into their production chain.

For those removable laboratories inclined to define themselves as comprehensive, I would like to present a few articles over this year, illustrating and explaining services that laboratories can offer to fortify or build their comprehensive service offerings.

Fine details are standard

A service I offer in the construction of immediate dentures, which follows the comprehensive mindset, is a palatal rugae transfer technique. Extolled almost 50 years ago in a paper written by Dr. Earl Pound, “Esthetic Dentures and their Phonetic Values,” the technique entails the simple transferring of the palatal landmarks (rugae) and functional contouring of vault space allowing for tongue and air flow control required to allow for easier phonetic adaptation for denture patients.

Personally I have found it most useful for not only immediate denture patients who have never had to adapt to a smooth, rugae free, incorrectly contoured vault, but also as a better functional alternative for existing denture wearers having a preformed manufactured palatal form that does not exactly resemble the anatomy it is supposed to recreate.

Copying nature

For immediate dentures, I begin by setting all the teeth for the arch, leaving the palate open except for the lingual contours required to allow for functional movements of the dorsum of the tongue used for air regulation through the center of the palate and forward (Fig. A).

Besides establishing the appropriate lingual fullness, setting the teeth for an immediate denture in this sequence allows a better discernment of the emergence profile of teeth, acrylic thickness at the junction of tooth to base and helps to develop the palatal form I will be replicating (Fig. B).

Once that palatal form is established I take an impression of the vault with PVS lab putty (Fig. C). Once set, I thermal form .020 coping material with my Proform vacuum former over the putty replication of the vault (Fig. D).

When cool, I trim to shape the replicated vault area and place it within the palate above the exact rugae I have copied using a tripod of pieces of baseplate wax (Figs. E, F & G).

The coping material is thin enough that the contours transfer through to the reverse side of the material, providing a smooth, contoured, non-irritating facsimile (Figs. H & I). The case is waxed final, flasked, processed and finished (Fig. J).

Suiting the patient

An alternative method for patients with preformed patterns in their existing dentures or those who have a smooth palate and may have whistling or other audible anomalies during speech due to poor vault contour and replication is to incorporate the rugae and contour into the baseplate used for the try-in stage of their treatment.

The basic technique for using putty to impress the palate and vacuum form over it is the same, except that the coping material is trimmed and placed on an uncured baseplate of VLC resin and cured. If, at the try-in appointment, the patient rejects or finds the pattern irritating it can be easily smoothed away or adjusted to accommodate the patient’s comfort. Once the try-in is approved, flask, process and finish as normal.

Remember, immediate patients have never worn a denture, so to them it only makes sense that the bumps, ridges and contours their tongue is accustomed to naturally exist in their dentures as well. If you would like an illustration of value, when you later make their definitive denture, try leaving the rugae off. If you do, just make sure before you do that you have a good post process technique for adding it.

Conclusion

I hope you found this technique informative and hopefully opened your thinking up to other services you can provide that project above average standards in your everyday work.

All the best. TomZ