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Esthetic Templates for Complex Restorative Cases:Rationale and Management

DEAN 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 utiliz-ing 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 invalu-able 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 opera-tor, patient, and entire interdisciplinary team to visualize the final esthetic outcome.

(J Esthet Restor Dent 20: 239–250, 2008)

I N T R O D U C T I O N

Dentistry continues to evolvewith new techniques and

materials; however, the success of

treatment is based mainly on diag-nosis and treatment planning.1

Complex restorative cases requiredifficult clinical decisions regarding

the final esthetic outcome inwhich the operator must visualizethe definitive restorative positionof the teeth. These critical

*Graduate student, Graduate Prosthodontics, Department of Restorative Dentistry,University of Washington, Seattle, WA, USA

†Associate professor and director, Graduate Prosthodontics, Department of Restorative Dentistry,University of Washington, Seattle, WA, USA

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decisions must be made beforetreatment is rendered. Communi-cating these decisions to the patientand the treatment team are crucialprior to achieving clinical success.2

The esthetic template isthe conduit for providingexcellent communication.

Esthetic templates are not provi-sional restorations; the templatesdescribed in this article are pre-provisionals that incorporate diag-nostically driven matrices thattransfer predicted tooth positionbefore any irreversible proceduresare performed. Confirming one’sclinical impression in the diagnos-tic phase reduces the risk forproblems during the course oftreatment. The goals of esthetictemplates are (1) patient visualiza-tion, (2) laboratory communica-tion, 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.3

By creating an esthetic templatefor fixed prosthodontic cases,the clinician can verify the finaltooth position before any irrevers-ible procedures are performed.In essence, this is the wax

rim concept applied todentate patients.

Various esthetic diagnostic tech-niques 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 tempo-rary technique,” which enables theclinician and patient to visualizethe definitive outcome. Once theesthetic goals are confirmed, thedentist can start preparing the teeththrough the preevaluative provi-sional, 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 sequen-tial decisions: (1) dentofacial analy-sis, (2) blueprint development,(3) matrix management, and(4) template application.

The purpose of this article is topresent a rationale for esthetic tem-plate selection and management ofseveral techniques for complexrestorative cases.

1 . D E N T O FA C I A L A N A LY S I S

In order to select the proper tem-plate, 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 verti-cal plane of space allows the visu-alization of the incisal edge length,proposed gingival location, andrelative position of the maxillaryocclusal plane (Figure 2A,B).5 Thehorizontal plane allows the clini-cian 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 visual-ize 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

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 S

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esthetic and an excellent patientand laboratory communicator, thusallowing for an accurate represen-tation of the proposed treatment

(Figure 4A–C).6 However, this tech-nique requires longer chair time, istechnically demanding, and is bestsuited for anterior esthetic cases.

Dental imaging can be effective forvisualization; however, a two-dimensional picture of a three-dimensional 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 labora-tory support is utilized to create ablueprint, which is the envisioned

Figure 1. Full preoperative facial view allows the clinicianto perform a dentofacial analysis.

A B

Figure 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.

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comprehensive plan based onthe dentofacial analysis, onthe diagnostic cast.

2 . B L U E P R I N T D E V E L O P M E N T

A 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 specifi-cally, 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 the

clinician to analyze the blueprintupon return from the laboratoryand ensure that it satisfies theesthetic vision.

After the analysis, the clinicianmust decide whether the blueprintis additive or subtractive. Somealterations are more predictablethan others when utilizing esthetictemplates. Movement of teeth api-cally and posteriorly is more diffi-cult, 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

recontouring teeth can shortenthem as described; however,moving teeth lingually is impossibleto achieve with an esthetic tem-plate. If the treatment plan incor-porates lingual movement, then thebest way to communicate with thepatient is the blueprint itself. Asopposed to moving teeth apicallyand posteriorly, moving teeth incis-ally and anteriorly is predictable,and there are many ways to accom-plish this outcome. These move-ments are considered additiveprocedures, which include length-ening 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 T

As soon as the clinician has deter-mined that the blueprint is addi-tive, 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 diagnos-tic 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

Figure 3. Lateral view of smile is used to visualize toothposition in the horizontal plane. Note the current positionis retroclined compared with the desired position.



duplicate the blueprint and createa vehicle for its transfer to themouth. The matrix is then filledwith a provisional material,approximated over the existingdentition, and allowed to cure.This technique allows a simple,low-cost way to verify plannedtooth position in an esthetic way.

With some treatment strategies,the blueprint matrix cannot be

approximated over the existingdentition because extensive ante-rior or sagittal movement wastreatment planned. Therefore, atechnique that uses a referencepoint other than the teeth must beutilized. The most stable referencepoint to use is the palate whenthe teeth are undergoingorthodontic movement. Typically,when using the palate as a refer-ence point, everything lingual to

the incisal edge is removed fromthe template, allowing it to beproperly oriented. This matrix isthen filled with a provisionalmaterial and approximatedover the diagnostic castusing an indirect technique(Figure 5A–D).

Once the clinician has made thechoice of which template techniqueto utilize, the last decision to make

A B

C

Figure 4. A, Initial image prior to the application of direct composite resin mock-up. Note no tooth display at restposition. B, Application of a direct composite resin mock-up (can be performed freehand or with a palatal matrix).C, Completed direct composite resin mock-up.

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is which material to select for theesthetic template. One of twochoices can be applied for esthetictemplate management. These mate-rials consist of polymethyl meth-acrylate acrylic (PMMA) andcomposite resin (bis-GMA,Protemp 3, Garant, 3M ESPE, St.Paul, MN, USA). Both of thesematerials provide excellent esthet-ics, color, detail reproduction, andare relatively easy to use.

A key factor in which of these twomaterials to choose is whether thistemplate should be removable orfixed. If the template needs to be

easily removed, then PMMAshould be the material of choicebecause the clinician can remove itduring polymerization to establisha path of draw. Large gingivalembrasures can pose a risk forlocking the template onto theteeth; wax or any blockout mate-rial should be considered. If thetemplate does not need to beremoved, bis-GMA is typicallyconsidered. These templates canthen be bonded to the teeth andworn as trial restorations orused as preparation guides foractual tooth preparation(Figure 6A–C).

4 . T E M P L AT E A P P L I C AT I O N

Esthetic templates possess a multi-tude of applications. The primaryuse of these templates in office isto facilitate clinician/patient com-munication. Allowing the patientto visualize the anticipated treat-ment result can align the clinician/patient esthetic vision whileconfirming the clinician’s clinicalimpression. Typically, patients willhave some esthetic changes or affir-mations about the template. Thetemplate promotes a dialoguebetween the clinician and patientthat possesses a much higher valuethan trying to explain the

A B

C D

Figure 5. A, A frontal preoperative smile of a patient requiring a comprehensive multidisciplinary treatment. An indirecttechnique will be used to simulate the prospective teeth position. B, A frontal preoperative view. C, A blueprintis created on the mounted diagnostic casts using a combination of orthodontic setup and diagnostic wax-up.D, Completed indirect removable template position on the diagnostic cast. Note the extensive alterations planned.



treatment goals on a mounted setof diagnostic casts. The patientessentially wears the final resultbefore any irreversible proceduresbegin. If esthetic modifications arenecessary to the matrix, then thesechanges are communicated to thedental technician, allowing theblueprint to be modified beforetreatment ever commences.

These templates can be designed asremovable appliances and given tothe patient to take home. Withcomplex restorative cases, the

alterations are usually significant.Treatment discussions can be veryoverwhelming for some patients;the template allows the patient anopportunity to take his/her timewhile retaining a visualization tool.At home, opinions of friends andfamily can aid in the patient’sdecision process.

Prerestorative template manage-ment facilitates multidisciplinarycommunication. The esthetic tem-plate enables the entire treatmentteam to visualize the definitive

treatment outcome in the patient’smouth in their own respectivepractices. Esthetic templates can beused to communicate periodontalprotocols, such as crown lengthen-ing, implant position, and mucog-ingival procedures. Visualization ofpredicted esthetic outcomes is noteasily managed when teeth are notin the ideal position and theirshape and contour are not optimal.As with many multidisciplinarycases, tooth provisionalizationcannot always be performed priorto orthodontic procedures, and the

A B

C

Figure 6. A, Initial smile prior to using a fixed template. B, A blueprint was created with the diagnostic wax-up.C, Completed fixed bis-GMA template in the patient’s mouth during smile.

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esthetic template allows an orth-odontist to utilize the blueprint inthe mouth as well (Figures 7A–Cand 8). Another application isusing the matrix from the blueprintto verify proper tooth alignment oreven movement progression. Thistechnique is more predictable thantraditional methods of measure-ment off the diagnostic wax-upand arbitrary relation back to thepatient’s mouth. Understanding therationale and management ofesthetic templates allows the clini-cian to apply the template not onlyin the diagnostic phase but alsoduring various stages of treatment.

A B

C

Figure 7. A, Preoperative smile prior to orthodontic movement. B, Blueprint was created with orthodontic setup anddiagnostic wax-up. C, Completed vacuum-formed matrix to verify orthodontic space appropriation.

Figure 8. Silicone putty matrix was generated from theblueprint to guide orthodontic treatment of the canine,utilizing the palate as a reference. Note that additionalmesial and apical movement of the cuspid is requiredto approximate the matrix.



S U M M A RY

In summary, a diagnostic rationalefor esthetic template fabricationand management has been pre-sented. Four sequential decisionsthat a clinician must contemplatewere discussed (Figures 9–12).When utilizing an esthetic tem-plate, the clinician must knowwhere he or she wants to put theteeth based on a dentofacialanalysis. The dentofacial analysismust then be communicated to

the laboratory and then a blue-print is developed from the diag-nostic casts. A matrix is thenfabricated from the blueprint andthen related back to the existingdentition. The esthetic template isan invaluable communicator thatcan be utilized in office, with thepatient at home, or even withinthe multidisciplinary treatmentteam. Clearly, the effective use ofesthetic templates demonstrates areversible way to visualize difficult

esthetic decisions before any irre-versible procedures are completed.Esthetic templates are a physicalmeans of communicationthat provide the patient,technician, and multidisciplinaryteam with an instrument topredictably manage complexrestorative cases.

D I S C L O S U R E

The authors do not have anyfinancial interest in the companies

Figure 9. Step 1: dentofacial analysis—preoperative viewof the patient’s smile.

Figure 10. Step 2: blueprint development—diagnosticwax-up.

Figure 11. Step 3: matrix management—vacuum-formed matrix prior to filling up withpolymethyl methacrylate acrylic.

Figure 12. Step 4: template application—polymethylmethacrylate acrylic template after vacuum-formed matrixremoval.

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whose materials are included inthis article.

R E F E R E N C E S

1. Amsterdam M. Periodontal prosthesis:twenty-five years in retrospect. AlphaOmegan 1974;67(3):8–52.

2. Marzola R, Derbabian K, Donovan TE,Arcidiancono A. The science of

communicating the art of esthetic den-tistry: part I: patient-dentist-patient com-munication. J Esthet Dent 2000;12:131–8.

3. Hickey JC, Zarb GA. Boucher’s prosth-odontic treatment for edentulous patients,9th ed. St. Louis (MO): CV Mosby;1985.

4. Gurel G. Permanent diagnostic provisionalrestorations for predictable results whenredesigning the smile. Pract Proced AesthetDent 2006;18(5):281–6.

5. Kokich V. Esthetics and anterior toothposition: an orthodontic perspective. partII: vertical position. J Esthet Dent1993;5(4):174–8.

6. Marcus R. Treatment planning and smiledesign using composite resin. Pract ProcedAesthet Dent 2006;18(45):235–41.

7. Magne P, Magne M. The diagnostictemplate: a key element to the comprehen-sive esthetic treatment concept.Int J Periodont Rest Dent 1996;16:561–69.



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