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Esthetic Templates for Complex Restorative Cases:Rationale and ManagementDEAN E. KOIS, DMD*KYLE K. SCHMIDT, DDS*ARIEL J. RAIGRODSKI, DMD, MS†ABSTRACTComplex restorative cases require difficult clinical decisions regarding the final estheticoutcome in which the operator must visualize the definitive restorative position of the teeth.These critical decisions need to be made before treatment is rendered. Communicating thesedecisions to the patient and the treatment team are crucial prior to achieving clinical success.The esthetic template is the conduit for providing excellent communication. The selection ofthe appropriate esthetic template is based on four sequential decisions: (1) dentofacial analysis,(2) blueprint development, (3) matrix management, and (4) template application. When utilizing an esthetic template, the clinician must know where the teeth should be placed based on adentofacial analysis. The dentofacial analysis must then be communicated to the laboratory,and then a blueprint is developed from the diagnostic casts. A matrix is then fabricated fromthe blueprint and then related back to the existing dentition. The esthetic template is an invaluable communicator that can be utilized in office, with the patient at home, or even within themultidisciplinary treatment team. Clearly, the effective use of esthetic templates demonstrates areversible way to visualize difficult esthetic decisions before any irreversible procedures arecompleted. Esthetic templates are a physical means of communication that provide the patient,technician, and multidisciplinary team an instrument to predictably manage complex restorativecases. The purpose of this article is to present a rationale for esthetic template selection andmanagement of several techniques for complex restorative cases.CLINICAL SIGNIFICANCEComplex restorative cases require difficult clinical decisions regarding the final estheticoutcome in which the operator must visualize the definitive restorative position of the teeth.The use of an esthetic template commensurate with a rationale for selection enables the operator, patient, and entire interdisciplinary team to visualize the final esthetic outcome.(J Esthet Restor Dent 20: 239–250, 2008)treatment is based mainly on diagnosis and treatment planning.1Complex restorative cases requiredifficult clinical decisions regardingINTRODUCTIONDentistry continues to evolvewith new techniques andmaterials; however, the success of†the final esthetic outcome inwhich the operator must visualizethe definitive restorative positionof the teeth. These critical*Graduate student, Graduate Prosthodontics, Department of RestorativeUniversity of Washington, Seattle,Associate professor and director, Graduate Prosthodontics, Department of RestorativeUniversity of Washington, Seattle,Dentistry,WA, USADentistry,WA, USA 2008, COPYRIGHT THE AUTHORSJ O U R N A L C O M P I L AT I O N 2 0 0 8 , W I L E Y P E R I O D I C A L S , I N C .DOI 10.1111/j.1708-8240.2008.00186.xVOLUME 20, NUMBER 4, 2008239

E S T H E T I C T E M P L AT E S F O R C O M P L E X R E S T O R AT I V E C A S E Sdecisions must be made beforetreatment is rendered. Communicating these decisions to the patientand the treatment team are crucialprior to achieving clinical success.2The esthetic template isthe conduit for providingexcellent communication.Esthetic templates are not provisional restorations; the templatesdescribed in this article are preprovisionals that incorporate diagnostically driven matrices thattransfer predicted tooth positionbefore any irreversible proceduresare performed. Confirming one’sclinical impression in the diagnostic phase reduces the risk forproblems during the course oftreatment. The goals of esthetictemplates are (1) patient visualization, (2) laboratory communication, and (3) clinician verification.These templates allow the patientto visualize predicted treatmentoutcomes directly in the mouth.Moreover, the esthetic templatecan be utilized to communicatekey esthetic information to thedental technician. Traditionally, inremovable prosthodontics, a waxrim has been used to evaluateprospective tooth position andmaxillary plane orientation.3By creating an esthetic templatefor fixed prosthodontic cases,the clinician can verify the finaltooth position before any irreversible procedures are performed.In essence, this is the wax240rim concept applied todentate patients.Various esthetic diagnostic techniques have been described in theliterature, such as direct compositeresin mock-ups, the use of indeliblepen, computerized dental imaging,intraoral tooth reshaping, anddenture teeth setup. Gureldescribed a “preevaluative temporary technique,” which enables theclinician and patient to visualizethe definitive outcome. Once theesthetic goals are confirmed, thedentist can start preparing the teeththrough the preevaluative provisional, which has been bonded tothe teeth, utilizing it as a toothreduction guide.4 Presently, onetechnique that facilitates estheticdiagnostics for complex clinicalscenarios has not been described inthe literature. Moreover, a rationalefor appropriate indications is stillneeded. Understanding which typeof template works well and whereit works is critical to which esthetictemplate the clinician chooses. Theselection of the appropriate esthetictemplate is based on four sequential decisions: (1) dentofacial analysis, (2) blueprint development,(3) matrix management, and(4) template application.The purpose of this article is topresent a rationale for esthetic template selection and management ofseveral techniques for complexrestorative cases. 2008, COPYRIGHT THE AUTHORSJ O U R N A L C O M P I L AT I O N 2 0 0 8 , W I L E Y P E R I O D I C A L S , I N C .1 . D E N T O F A C I A L A N A LY S I SIn order to select the proper template, the most important questionto answer is where the teeth belongin the face (Figure 1). Based on theclinician’s dentofacial analysis,tooth position can be described inthree planes of space: vertical,horizontal, and sagittal. The vertical plane of space allows the visualization of the incisal edge length,proposed gingival location, andrelative position of the maxillaryocclusal plane (Figure 2A,B).5 Thehorizontal plane allows the clinician to visualize the anterior andposterior position of the incisaledge (Figure 3). The sagittal planecomprises the dental midline andthe mesial and distal position ofthe teeth. Typically, the cliniciancombines movements in theseplanes of space in order to visualize the final tooth position. Oncethe desired position of the teethhas been verified, the clinicianmust decide whether laboratorysupport is needed.If minimal alteration is indicated,the clinician may choose betweenthe direct composite resin mock-uptechnique, dental imaging, maskingof selected areas of the teeth withan indelible black marker, orremoval of tooth structure.Minimal alterations are performedin cases such as mild attrition, milderosion, peg laterals, or diastemata.The direct composite resinmock-up technique is highly

KOIS ET ALesthetic and an excellent patientand laboratory communicator, thusallowing for an accurate representation of the proposed treatment(Figure 4A–C).6 However, this technique requires longer chair time, istechnically demanding, and is bestsuited for anterior esthetic cases.Figure 1. Full preoperative facial view allows the clinicianto perform a dentofacial analysis.ADental imaging can be effective forvisualization; however, a twodimensional picture of a threedimensional object does notprovide critical three-dimensionalinformation. The technique ofmasking selected areas of the teethwith an indelible black markerrequires minimal chair time and iseasy to perform but is restricted toshortening teeth. Recontouringteeth with a bur is also relativelysimple to perform; however, it isan irreversible procedure.Extensive alterations are performedin cases such as moderate-severeattrition and erosion, modificationsin contour and position, missingteeth, and orthodontic movement.Often, this type of alteration isoutside the clinicians’ comfort leveland overly time consuming toperform chairside. If extensivealteration is indicated, then laboratory support is utilized to create ablueprint, which is the envisionedBFigure 2. A and B, Frontal view of lips at rest position and high smile are used to visualize the definitive tooth positionin the vertical plane.VOLUME 20, NUMBER 4, 2008241

E S T H E T I C T E M P L AT E S F O R C O M P L E X R E S T O R AT I V E C A S E SFigure 3. Lateral view of smile is used to visualize toothposition in the horizontal plane. Note the current positionis retroclined compared with the desired position.comprehensive plan based onthe dentofacial analysis, onthe diagnostic cast.clinician to analyze the blueprintupon return from the laboratoryand ensure that it satisfies theesthetic vision.2. BLUEPRINT DEVELOPMENTA diagnostic wax-up is createdbased on the clinician’s dentofacialanalysis and esthetic judgmentcommensurate with the patient’svision. Some restorative casesrequire a multidisciplinaryapproach with the involvement ofvarious specialties.7 More specifically, orthodontics necessitatessome form of setup for treatmentvisualization. This information canbe transferred to the laboratorytechnician, who can now developthe blueprint. Before movingahead, it is important for the242After the analysis, the clinicianmust decide whether the blueprintis additive or subtractive. Somealterations are more predictablethan others when utilizing esthetictemplates. Movement of teeth apically and posteriorly is more difficult, if not impossible, to perform.These movements are consideredsubtractive procedures, whichinclude shortening teeth, narrowingteeth, and moving teeth lingually.This type of movement haslimitations because the teeth areusually in the way. Masking or 2008, COPYRIGHT THE AUTHORSJ O U R N A L C O M P I L AT I O N 2 0 0 8 , W I L E Y P E R I O D I C A L S , I N C .recontouring teeth can shortenthem as described; however,moving teeth lingually is impossibleto achieve with an esthetic template. If the treatment plan incorporates lingual movement, then thebest way to communicate with thepatient is the blueprint itself. Asopposed to moving teeth apicallyand posteriorly, moving teeth incisally and anteriorly is predictable,and there are many ways to accomplish this outcome. These movements are considered additiveprocedures, which include lengthening teeth, widening teeth, movingteeth facially, and replacing missingteeth. Once the clinician knowsthat the alteration is additive, he orshe is ready to create the matrix.3 . M AT R I X M A N A G E M E N TAs soon as the clinician has determined that the blueprint is additive, the next step is to create amatrix and transfer the blueprintto the mouth. At this point, theclinician knows the blueprint andneeds to relate the matrix back tothe existing dentition. In mostcases, transferring the blueprint tothe mouth is accomplished with amatrix fabricated off the diagnostic wax-up/setup. These matricescan be fabricated off the castusing two distinctive approaches:a vacuum-formed template or adirect impression with eithersilicone putty or irreversiblehydrocolloid as matrix material.These materials essentially