Re-Exploring Template-Driven Dentistry

INTRODUCTION
There is no denying that much of our continuing education consists of listening to lecturers who simply remind us of things we used to know. Such “refresher sessions” may unearth a concept that we had intended to embrace; or they can simply stir the coals of what we might currently be dabbling in, but haven’t yet made a standard part of our repertoire. We’ve all had those “Oh yeah, I remember that!” moments. To that end, I would like to “recap” the concept of template driven dentistry that I’ve written and lectured about for the last 12 years. The process takes on an ever-increasing importance when one considers the evolution of composite. This is especially true with respect to longevity and finishing properties of the new composites and also when one notes the state of our economy.
You might consider template-driven dentistry to be dentistry’s version of “paint-by-number” artistry. Those of you old enough to remember the “nondigital” age may recall passing time by creating artwork simply by keeping a half dozen colored paints within your designated color boundaries to create a mosaic. If you stood back far enough, your paint-by-number creation resembled a professional painting (Figure 1). The more colors and the finer the color boundaries, the more convincing the “art.”
Template-driven dentistry’s concept is similar. Following a lab-derived prototype of a smile design, we are provided templates that can be used to guide our restorations. If we keep our tooth preparations and restorative materials “within the lines” of the template provided, we can either indirectly (via the work by the laboratory team) or directly (with composites resins) emulate the prototype created. In doing so, the “heavy lifting” (artistic prowess) is off-loaded to our capable laboratory team, leaving us with the sole responsibility of providing appropriate treatment planning, excellent records, and a steady and judicious hand when preparing and finishing our creations. Over the years I have embraced this approach, and have been using composite nearly as frequently as porcelain. As our nation’s “ability to pay” has declined, I have found composite resin solutions to gain an increasingly higher case acceptance ratio over ceramic solutions.

Figure 1. Typical paint-by-number “masterpiece.”	Figure 2. The Resin Replica from Smile-Vision.
Figure 3. The hard-soft template.	Figure 4. The reduction or prep guide, with holes to allow a periodontal probe to estimate reduction adequacy.

Waxing up a case is nothing new; these are often called “white wax” prototypes or diagnostic wax-ups. Certainly many labs provide these and some form of template, whether it be a silicone putty mold of the wax-up or some sort of vacuum-formed stent. For many years, I’ve turned to Smile-Vision (Newton, Mass) to assist me in this area. Their approach includes a computer-artist generated smile simulation (as the blueprint) and a composite resin “wax-up” (dubbed “the resin replica”), and is highlighted by their “hard-soft” template. The final piece of the package is a reduction guide, enabling the clinician to evaluate tooth reduction with a periodontal probe (Figures 2 to 4). This “kit,” as I like to think of it, can be used in ways limited only by your imagination, as you will see. Smile-Vision’s underlying goal is to have the final restoration, either composite or ceramic, reproduce what is seen in the patient approved smile simulation. Experience has taught me that they are quite good at this, using a host of proprietary techniques to accomplish the task. The most critical tool in the kit is the hard-soft template. It is composed of a rigid outer shell that allows the operator to lean on it when forming plastic teeth (bis-acryl provisionals or full composite crowns/veneers) without fear of deformation of the highly detailed soft template portion of the matrix. Therein lies the ability to accurately transfer the resin replica prototype to the dentition.
Let’s take a look at some clinical cases so you can get a feel for how template-driven dentistry approach empowers us.

CASE REPORTS
Case 1
Kyle, a healthy 13-year-old male, had the misfortune of losing both of his central incisors during a playground accident. Prior to my meeting Kyle, an orthodontist had moved his laterals, canines, and bicuspids toward the midline to “fill the gap,” so to speak, and then called upon me for a cosmetic solution to the dental mismatch (Figure 5). Given Kyle’s age and anticipated dental/facial maturation, a composite solution seemed appropriate. The prospect of applying that much resin “free hand,” however, was daunting. I elected to first send a facial portrait of Kyle to Smile-Vision so as to envision what might be accomplished. Showing this simulation to Kyle’s mom elicited both tears (of joy) and a “let’s do it” with respect to the composite restoration (Figure 6).

Figure 5. Adolescent with missing central incisors, post-orthodontic treatment.	Figure 6. Pre-op simulation of an anticipated smile rehab.
Figure 7. Injection of composite into specially prepared “suck down” splint.	Figure 8. Finished case, demonstrating complete transfer of the resin replica morphology.
Figure 9. Porcelain conversion of a composite resin case, 5 years later.	Figure 10. Pre-op of post-orthodontic anterior dentition in need of “sprucing up” for a wedding.

After considerable discussion with Jon Brooks (an MDT and chief technician at Smile-Vision), we arrived at a “split-splint” modification of the soft portion of the hard-soft template. Following the resin replica fabrication that closely resembled Kyle’s smile simulation, the soft portion of the corresponding template was created and then altered by separating each interproximal contact of the anterior teeth with a scalpel blade. This allowed for the interproximal introduction of Mylar strips (Henry Schein) intended to isolate each tooth during the direct bonding process. Making a small port hole in the labial surface of each tooth allowed for injection of composite into the template, enveloping the tooth surface that had been prepared (as if done for porcelain veneers) and coated with bonding agent (Xeno 4 bonding agent [DENTSPLY Caulk]) (Figure 7). In an hour’s time, all 6 of Kyle’s teeth had been bonded.
Once the template was peeled away, my primary responsibility consisted of removal of excess composite, final trimming, polishing, and then finally adjustment of the occlusion (Figure 8). A time-tested composite resin was chosen for this case (TPH3 [DENTSPLY Caulk]). Due to its toughness and creamy consistency, this material lent itself to this approach since it flows freely without needing to warm the composite. Subsequent cases performed in this manner, which have found me using stiffer composites (such as Synergy D6 [Coltène]) or GrandioSO [VOCO America]) have necessitated warming of the composite for better flow. This is easily accomplished with a composite warmer (Calset [AdDent]), an item that remains an everyday mainstay in my practice, with respect to composite handling and placement. The final treatment plan called for conversion to porcelain veneers at age 18 years, which was accomplished happily at that time. During the 5-year stretch, occasional repairs were performed, but these amounted to nothing more than low-maintenance, low-frequency upkeep (Figure 9).

Case 2
A similar case to Kyle’s presented, but with one pleasant twist. Another post-orthodontic patient, seeking an aesthetic prewedding upgrade of her 4 anterior incisors, presented with a fixed lingual retainer spanning teeth Nos. 6 to 11. As an all-ceramic solution did not fit her budget, composite resin was chosen to restore the appearance of teeth Nos. 7 to 10. The chief issues to correct centered on old and discolored bonding, and an endodontically treated and darkened tooth No. 10 (Figure 10).
The “luxury” of the retainer made it unnecessary for me to use the “split splint” approach, since the teeth were already connected and required floss-threaders to maintain. In this instance, both the hard and soft templates were used to restore the smile. The resin system chosen (Amaris [VOCO America]) allowed for a dual-layering approach, due to its assortment of dentin shades, 2 enamel shades, and 2 very effective opaquing materials. The HO Opaquer (VOCO America) was instrumental in taming the dark shade found in tooth No. 9 (Figure 11). In an effort to create a more lifelike smile, both enamel and dentin shades were combined within the soft template, seeking an incisal translucency effect (Figure 12). The overall approach to the case was the same as outlined above: patient approved simulation, resin-replica mock-up, and template fabrication. In this instance, since separation was not an issue, the hard-soft template was loaded as if one were doing a bonded veneer temporary. Then, it was seated atop the prepared tooth that had been coated with a bonding agent (Futurabond [VOCO America]) and light-cured. Tooth preparation resembled traditional veneer preparations and tissue shaping with a diode laser (ezlase [BIOLASE Technology]) was also done for better visual symmetry. As has been alluded to, adequate tooth preparation was facilitated by use of the templates provided. Placement takes little time, while cleanup, polishing, and final shaping will keep one busy for the majority of the appointment (Figure 13).

Figure 11. Dark shade of an endodontically treated tooth being blocked out (HO Opaquer [VOCO America]).	Figure 12. Mix of dentin and enamel shades within the Smile-Vision template.
Figure 13. Final result. Note the polychromatic look, as well as the symmetrical arrangement of the bonded composite restorations.	Figure 14. Bicuspid prep, lubricated with glycerin to allow for easy removal of the indirect composite veneer.

Case 3
In this instance, the template approach was used to create a “hybrid case” that included both composite resin veneers and porcelain veneers. Hybridization of such cases can sometimes help shave just enough off of the case fee to fall within your patient’s price point. In this instance, an 8-unit veneer case consisted of porcelain veneers on teeth Nos. 6 to 11 and composite veneers on teeth Nos. 5 and 12 that were fabricated “indirectly” using the soft template portion of the hard-soft template.
Following conventional preparation for porcelain veneers on teeth Nos. 5 and 12, both were coated with a glycerin-based lubricant that was blown thin. Warmed (shade A1/B1) composite resin (Synergy D6) was injected into the bicuspid sections of the soft template and applied to the arch, followed by the hard shell portion of the template. Following light-curing, the templates were removed and the bicuspid veneers plucked from the soft shell. They were then trimmed in hand with an 8-bladed carbide finishing bur (Brasseler USA). The composite veneers were then bonded to teeth Nos. 5 and 12, using One Coat Bond (Coltène) and the flowable version of Synergy D6. For all practical purposes, those were completed.
The final impression for the porcelain veneers followed as did the application of the bonded provisional from teeth Nos. 6 to 11, using the same hard-soft template employed to fabricate the bicuspid composite veneers. Case completion occurred 4 weeks later with the delivery of porcelain veneers (DENTSPLY Ceramco porcelain) (Aesthetic Porcelain Studios) (Figures 14 to 18). Again, the entire process was template guided and based upon a patient approved smile simulation and the accompanying template kit. You need only use your creativity to see how this indirect approach can open new doors. Imagine how this might ease a large diastema closure assignment.

Another Kind of Template
There are templates, and then there are templates. You may have noticed the re-emergence of products that are designed to be one-visit smile solutions (such as Componeers [Coltène] or Edelweiss [Ultradent Products] composite veneers) (Figure 19). These products are reminiscent of what was formerly called “Mastique” (DENTSPLY Caulk), introduced in the early 1980s. Though a short-lived product, owing to the property limitations of the earlier resin materials and bonding agents, the concept has remained alive. In essence, we are dealing with preformed anatomical tooth forms that serve as a scaffolding for resurrecting the surface of an anterior tooth. We refine the size and shape to meet our goals (according to the underlying tooth substrate), and backfill the composite shell with a like material. In the case of the Componeer, the shell itself is composed of the same resin that is used to lute it: Synergy D6. Upon curing, the paste and shell become homogeneous. The end result of a typical case is anatomic accuracy and visual symmetry that only the finest of composite jockeys could ever hope to accomplish. Once again, the template does the heavy lifting of achieving “the look,” while we are simply relegated to cleaning up, polishing, and adjusting. While strenuous, the anxiety associated with not knowing if your creation will please the eye, is significantly reduced, if not eliminated (Figures 20 to 22).

Equipping for the Process
While enabled by judicious use of templates to take our aesthetic feats to new levels, there is no escaping the fact that, while doing such cases, we are sitting for long periods of time. It is incumbent upon the dentist who wishes to pursue this kind of dentistry to obtain a comfortable, ergonomic dental operator’s stool that can provide support for one’s back and arms. There are several on the market designed to move with you as well as reduce low back strain (SurgiTel’s Ergo-Comfort and RGP Dental’s 400-D). You pass by them frequently at regional dental meetings. Try them out. You can usually return them if they prove to be uncomfortable.

Figure 15. Composite resin (Synergy D6 [Coltène]) placed within the soft template, ready to press to the tooth surface for curing.	Figure 16. Trimmed composite veneer; prebonding.
Figure 17. Composite and porcelain veneers in place (teeth Nos. 5 to 8).	Figure 18. The completed smile rehab, combining composite resin and porcelain veneers.
Figure 19. Componeers (Coltène) placed on teeth Nos. 6 to 11.	Figure 20. Pre-op photo of old composite bonding; to be replaced by a new set of Componeers.
Figure 21. Componeers, placed in a single morning.	Figure 22. A very happy patient displaying her new Componeer smile!

Above all, superior vision is a must when removing composite resin that is in close proximity to the gingival tissues. The reasons are obvious. The 2.5x magnification used by many operators, in my opinion, is not enough to enable vision acute enough to consistently spare tissue from nicks and abrasion. I transitioned to more powerful magnification throughout the years and now employ compact loupes at a power of 5.5x (Compact Prism Loupes [SurgiTel]), having had stops in the 4.0 to 4.8x range along the way. In order to provide proper illumination, a loupe-mounted LED light is needed for this level of magnification. The LED light by SurgiTel (Micro LED) has been useful in that regard. With the extra light, you will be less likely to experience any eye strain, and it will liberate you from the overhead chair light. That can be a wonderful feeling.

STEPPING OUTSIDE OF YOUR COMFORT ZONE
So there you have it—a recap of some of the items that I have covered throughout the years, presented with the hope of rekindling some fires within you. Getting involved may require that you step a bit outside of your comfort zone. However, doing so will increase the options that you have to offer your patients, and will certainly help to increase your bottom line. It might even make your job more interesting. If you manage to produce some dazzling cases using any of these approaches, I would love to see them.
Over and Out!

Dr. Goldstein, a Fellow of the International Academy of Dento-Facial Esthetics as well as the AGD, practices general dentistry in Wolcott, Conn. Recognized as a Leader in Continuing Education by Dentistry Today since 2002, and for his expertise in the field of dental digital photography, he lectures and writes extensively concerning cosmetics and the integration of digital photography into the general practice. He has authored numerous articles for multiple dental periodicals both in the US and abroad. He can be contacted at martyg924@cox.net or at drgoldsteinspeaks.com.

Disclosure: Dr. Goldstein is a consultant to Smile Vision and Coltène.