The internationoi Journai of Periodontics & Restorative Dentistry

5Ó1

The Diagnostic Template: A Key

Element to the Comprehensive
Esthetic Treatment Concept

Pascai Magne.DMD* Currently provisional prostheses

Michel Magne. CDT" play an important roie during
UrsBelser.DMD-" the various stages ot an oral
rehabilitation.' porticulorly if
extensive restorations within the
visibie regions are involved,^"^
During this cruciol phase of
treatment, the comtort of the
potient must be maintained. The
Provisionai restorations represent a i<ey eiement in the realization ot exten- patient offen feeis uncomforf-
sive esthetic rehabiiitations. in particular, they provide indispensibie diog- oble during this provisional
nostic intormotion, contribute signiñcontiy to adjocent soft tissue condition- period. The fear of fraotures or
ing, and ensure the patient's comtort during the intermediate phase of the embarrassment of display-
treatment. The treatment outcome strongly depends on the treatment ing unesthetic restorations
approach chosen. This articie describes a treatment rationoie comprising mokes it difficult to lead a nor-
the use of o diagnostic tempiate. This typo of work strategy, documented moi social lite. Therefore, the
with ciinicai cases, integrotes diagnostic waxups ond indirect provisional
olinician should aim to make
restorations using simplified and efficient fabrication techniques.
the provisionai period as com-
(Int J Periodont Rest Dent 1996; 16:561 -569)
fortoble as possible, which wiil
contribute to the estabiishment
of a reiotionship between the
patient, the clinician's team,
ond the dental iaborqtory
team, ond will have a positive
"Leoturer. Division of Fixed Prosthodontics ond Division of impact on the treatment out-
Operative Dentistry and Endodontics, University of Genevo
come.
School of Dentistry Geneva, Switzerland.
"Ceramist, Dental Loboratory Oral Design. Montreux, Switzerland. The provisionoi phase shouid
"Professor and Ctiairman. Deportment of Prosttiodontics, aiso be considered o diagnostic
University of Geneva School of Dentistry. Geneva. Switzerland. phose.^"'' Ciearly, extensive
esthetic rehabilitations require a
Reprint requests: Dr Poscal Magne. 19 rue Barthélemy-Menn,
1205 Geneva, Switzerland.
specific therapeutic approach

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562

Final Final
impression restorations
Preliminary Diagnostic costs
impresslohs
Simpie coses

Finai
Direct impression 2
provisionai restorations

\
Compiex cases
Tootti
preporotions Loboratory
Final provisionoi and
impression 1 post-and-oo re
restorations

Fig 1 Treatment scheme.

to allow the precise definition ot situation; the mast difficult cases

the finai prosthetic configura- require the most significant
tion. Not oniy must the finai pros- etfort. This articie describes a
thesis meet various functionai rational approach to providing
requirements such as anterior provisional prostheses by using o
guidance, but it must also be in diagnostic template. The tem-
harmony with the surrounding plate consisted of a diagnostic
sott tissues and with the waxup, followed by the fabrica-
patient's individual smile, tace, tion of provisional restorations
and character. Provisional incorporating optimum function
restorations represent a key eie- and esthetics. Novel and simpli-
ment in this approach. fied fabrication techniques
The modern treatment con- ("veneered waxup" and "sand-
cept abandons the traditional wich" provisional restorations)
practice of obtaining patient are presented and docu-
satisfaction by using a provi- mented with ciinicai cases. The
sional restoration of mediocre authors wish to emphasize the
quaiity that is iater replaced by objectiveness and simplicity of
a significantly improved fixed the approach, as weli as its prof-
prosthesis. Instead, the treat- itability because of its use of
ment objective is reached by a diagnostic information that is
diagnostic effort in proportion to invaluable to the fabrication of
the complexity of the initiai the finai restoration.

The International Journai of Periodontics & Restorative Dentistry

 563

The diagnostic template: guidelines in obtaining a glo- restorations shouid be made

An integrated approach bal esthetic integration ot the using an indirect technique
prosthesis-^ that includes the and can be fabricated simulta-
Therapeutic scheme arrangement of teeth and distri- neously with post-and-core
bution af space in harmony with restorations. For fixed partiai
Esthetic rehabilitation cases the face shape, age, and char- dentures (FPDs), the soft tissue
can be divided into at least acter of the individual patient. configuration of the edentulous
two groups, each requiring dif- At this stage of treatment, areas should be corrected
ferent degrees af creative communication between the before the first precision impres-
capacity trom the ciinicai and patient and dentai technician is sion (Figs 2d and 2e). During a
technical teams in charge^: (!) criticai. Only a direct diaiogue subsequent appointment, the
ciinicai situations in which the finai cementotion of the post-
(between the patient and the
and-core restorotions and the
restorative effort is limited to the dentai technician) can guaran-
piacement of the provisionoi
reproduction of one or several tee the success of this ap-
restorations may be performed
jntaot teeth used as refer- proach. The ciinician should not
(Fig 2f). Once the sott tissue
ences; and (2) more complex act as mediator.' After initial conditioning has been judged
rehabiiitations of an entire therapy and preliminary tooth to be adequate, the tooth
onterior segment, in which the preparation, a tirst generation of preparations have been final-
arrangement and shape of the direct provisionai restorations ized, and the "diagnostic tem-
teeth, as weli as the distribution should be incorporated. These plate" has been approved by
of spoce, must be redesigned. provisionai restorations are nor- the patient (Fig 2g), a second
The treatment approaches maiiy fabricated intraoraiiy by and finai impression is taken for
for the two groups of patients the production of a direct resin the fabrication of the definifive
must be differentiated. The moid using a siiicon key derived restorations (Figs 2h to 2j),
treatment scheme is proposed fram the diagnastic cast. When
in Fig 1. For ail oases, the first an existing extensive recon-
phase of treatment consists of struction has to be removed
fhe fabrioation of diagnostic (Figs 2a and 2b), a sheil-type
casts upon which the desired provisionai restoration can be
position and morphology of prepared in the laboratory and
teeth and gingivae are deter- can subsequentiy be reiined in
mined. This waxup, or set-up, the patient's mouth (Fig 2c). For
performed by the dentai techni- simple cases, the fabrication of
cian, considers: (1) objective this first provisional restoration
porameters, or ciinicai guide- can be foiiowed by the finai
lines related ta the extensian preparation and impression.
and the type of restoration For the construction of
planned and the basic criteria more extensive prostheses, the
of orol esthetics*; and (2) sub- tirst precision impression wiii
jective parameters, based an aiiow a more detaiied anaiysis
individuai criteria of orai esthet- of the ciinicai situation tor the
ics and on the patient's per- fabrication of the second gen-
son ai ity. In complex oases eration of provisionai prosthe-
both parameters are used as ses. The second provisionai

Volume 16, Number 6,1996

564

figs 2o ond 2b An anesthetic ceramomefai maxillary fixed partiai denture extends Fig 2c Affer removal af the prasthesis.
from the right ñrst premolar to the left canine. The iaterai incisors are missing, and the a sheti-type acryiio provisional restara-
canines are nanvitai. fian is relined and adjusted intraarally.
Nate the inadequate pasitian of the
right canine that features an insufficient
root length and advahced loss ot
periodantai attachment

Fig2d Following ri:c ^xriaction of the Fig 2e At the time af fhe elecfra- Fig 2f Incomplete insertion ot the .cra-
right oanine ond healing at the site. surgery, the ieft canine is prepared for visianal restaratians underlines the
corrections to the oonfiguratioh af the a cast past-and-care restaratian. A close relationship of the restorations
edentulous ridge ore made using eiec- precisich impression is taimen using an with the surrouhding saft tissues fhat
frasurgery and subsequently fhe provi- elastamerlc material. The respective are still heaiihq.
sional prosthesis ta guide the soff tissue working cost is used for the fabrication
contaurs. of both a cast pasf-and-core restara-
tian and two indirect provisional fixed
partial dehtures using the 'sandwich"
technique.

The International Joumal of Periodontics & Restorative Dentistry

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Fig 3gí (left) Final impression is taken

after all signs of inñammafian have dis-
appeared, which proves that the quaiity
of fhe provisional restoration has led to
optimal conditioning ot the gingival tis-
sues. Note the adequate integration of
the provisionals into the patient's smile.

Fig 2h (rignt) Soft tissues beneath the

pontics of the corresponding fínol pros-
thesis have heaied.

Figs 2i and 2¡ Detinitive ceramometai

fixed partial dentures constitute the
exact reproduction ot the provisional
restorations in relation to the soft tissues
ond their giobal integration.

Detinlfion and characteristics of Because it is derived from a impression and limits the risk
the diagnostic template diognostic waxup ond/or of esthetic and biologic
set-up procedure, it permits complications,"^''"
The creation of a diagnostic a diagnostic evaluation that Using silicon keys derived
template is a key element in this may reveal the need for from the diognostic study, it
opproach. It can be defined as specific intervention during guides the taPricotion of
the sum of the procedures un- the preprosthetio phase cost post-and-core restora-
dergone to: (I) determine the (tor gingivoi recontouring, tions and controis the reduc-
form and position of teeth and crown-lengthening, ortho- tion of mineralized tissues
the surrounding gingivai tissues dontic therapy, etc). during tooth preparation,
on the mounted diagnostic With provisionoi restorotions it allovi/s clinicians to pro-
casts (waxup, set-up), and (2) odequately adapted and ceed without uneasiness
evaiuate, in the ciinicai environ- contoured, it permits the regarding the fobrication of
ment, the global integration of conditioning of the soft tis- the tinai restorations because
the new orai design. The advan- sues surrounding abutment the provisionals are evalu-
tages of o diagnostic template teeth^ and the edentulous ated daily ond finaily ap-
ore numerous: ridges. This facilitates the final proved by the patient.''

Volume 16, Number 6,1996

5Ó6

Veneered waxup

The diagnostic analysis is the

basis upon which future fheropy
is pionned; however, fhe diag-
nosfic analysis shouid remain o
simpie and rafional procedure. If
exfensive prosthetic rehabilita-
tions are indioated. it is advis-
able to communicate with the
patient using concrete exam-
ples. Computer imaging has
Figs 3a and 3b Models cf intact natural dentitions were used to generate different become an attractive and
sets af vestibuiar wax veneers (Wax-Up Structures, Michel Magne Dental Group,
Switzerland). modern tooP''^^; however, one
should not neglect the more
elementary sources of intorma-
tion, such as examples of
restorations, former photographs
of the patient, fashion maga-
zines, and—most of aii—models
of intact naturai dentitions that
the dental technician has coi-
lected over time, intuition, sensi-
tivity, and a good perception of
the patient's individuai chorac-
Figs 3c The arrangement ot the teeth Figs 3d The veneers of gray wax have
can easily be obtained and modified interdental wings and took like three ter shouid help the technician to
by individually positioning the veneers quarter orowns of 1 mm thickness define a preiiminory prosthetic
on the working cost
goal, essentially based on one
or several preselected models of
intact dentitions. A meticuious
selection ot modeis of intact
dentitions has been used to
generate vestibular wax veneers
(Wax-up Structures. Michel
Magne Dental Group) (Figs 3a
qnd 3b), These ore subsequentiy
positioned on the patient's cast
(Figs 3c and 3d) and finally
Fig 3s Once the position of the teeth is Fig 31 The palatal and incisai aspects completed with wax (Figs 3e
judged ta be adequate, the addition af of the teeth are the only valûmes that
wax aiiows the rapid compietiqn af the
and 3t). thus the term "veneered
have to be carved Individually In rela-
diagnastic waxup on its buccal side. tion ta the fuhctian. waxup." This method oan pro-
duce naturai waxups indepen-
dent ot the operator's artistic
talent. Furthermore this metiiod

The International Journal of Periodontics a Restorative Dentistry

 567

requires considerably iess time the waxup (Fig 4a). To obtain a

than a classic fuil waxup. precise key, the cast can be
subjected to a pressure of 4
atmospheres during the setting
Sandwich provisional of the siiicone materiai, A first
restorations mixture of self-curing acrylic
(Outline Acryl, Macal) with an
The previously described diag- opacity similar to that ot dentin
nostic effort can only be truly is applied to the working cast
appreciated once it has been using the siiicone key, whioh
transferred to the patient's perfeotiy reproduces the wax-
mouth. There remains an vivo up (Figs 4b and 4c). Atter gross
method that aiiows the prepa- reduction, a homogeneous
ration of an esthetic waxup that layer ot resin is eliminated
can be tried in clinically. An vestibular iy. pa lata I Iy, and
esthetic evaiuation. however, incisa i iy
requires a prolonged trial of sev- This attempt to reproduce
erol days or even weeks. It is of the morphology of dentin can
primary importance that the be easily checked using a sec-
patient feel comfortable during tioned siiicone key (Fig -Id). A
the entire diagnostic period. bonding resin may be applied
Only by reproducing the waxup (Fig 4e) to provide adhesion for
in the form of an indirect provi- photopolymerizing coiorants
sionai restoration can these (Fig 4f). The ooiorants accentu-
requirements be fully satisfied, in ate the saturation interproxi-
addition, specitic corrections maiiy and at the cervical level
may be suggested by the ciini- and simuiate certain incisai
cian and the patient. The new characteristics (fissures, color-
technique ot stratification, or the ations, etc). Self-curing acrylic
so-called "sandwich tech- material (Outline Acryi. Mccoi)
nique," gives the technician the that reproduces the trans-
opportunity to produce provi- parency of enamel is finaliy
sional restorations with a natural molded tc the previous layers
oppearance and in-depth with the same matrix derived
characterizations. This proce- trom the originai waxup (Fig
dure has aiso been developed 4g).The final result consists ot a
to obtain restorations that will •'sandwich" of different acrylics
not lose their basic aspect as a that include intense colorants
result of surface changes such that are iocated in the interior,
qs grinding corrections and and with a surtoce that can
consecutive relinings. be modified and polished
The first step in the sand- mechanicqily without ioss of
wich technique consists ot con- inherent color characteristics
structing q siiicone matrix on (Figs4hto4j),

Volume 16, Number 6,1996

568

Fig 4a A precise siiicone key is pro- Figs 4b and 4c A first mixture of self-curing acryiic resin is brought into the siiicone
duced under 4 atmospheres of pres- matrix and pressed onto the previousiy isoiated master modei. The poiymerized
sure. acryiic resin perfectiy replicdtes the diaghostic waxup

Fig 4á To reproduce the aspect of Figs 4e and 4f A iayer af bonding resin (left) is appiied to ensure the adhesion of
dentine, the restoration must be uni- an ihtenseiy ootored photopalymerizing acryiic (right).
formiy reduced.

Fig 4g (left) nie photopoiymerizing

acrylic is covered by a second mold of
a more transparent, self-curing resin.

Fig 4h (right) ,4s a resuit of this sand-

wichlike composition of acryiio resin,
the surface of the provislcnai restora-
tions can be modified without losing
the shade characteristics as the iatter
are integrated deep in the bulk af the
restoration.

Figs 4iand4i After a last review af

the marginai adaptation an single dies.
the provisional restoratiohs con be
evaluated in vivo.

Ttie International Journal of Periodonfics & Restorative Dentistry

 569

Conclusions effort is assisted by the clinician ó. Kopp FR, Beiser U. Esthetic checklist
and the patient in defining, by for the fiited prosthesis, in: Scharer R
Rinn LA, Kopp FR (eds). Esthetic
Compiex cases of esthetic means of clinical corrections, Guidelines foi Restorative Dentistry,
rehabilitations oan be consid- the optimal configurafion of Caroi Streom, iL: Quintessence,
ered rationaiiy and predictably the provisional restoration. The 1982:187-192.
using a diagnostic template faithful reproduction ot the pro- 7, Doiie P Fauoon PH, Lemaitre D.
thot comprises two steps: visional restoration into the final Entretien au coin du four ovec Wiiii
Gelier. Premiere p a r t i e . Rev Fr
restoration will simplify its real- Prothese Dent. Février 1992:23-31.
1, A diagnostic analysis is ization considerably. 8, Kopp FR. Esthetic principles for fuil
mode on diagnostic casts crown restorotions. Part ii, Rro-
to redefine form and posi- visionalizotion, J Esthet Dent 1993:5:
258-264.
tion of teeth and surround- Acknowledgments
ing sott tissues. This can be 9, Donaldson D, The etiology of gingi-
The authors express their gratitude to Dr val recession ossociated with tem-
carried out simply and porary crowns. J Periodonfoi 1974:
B. Dubrez, Division of Rhysi o pathology
rapidly, whether or not the and Periodonfios, University of Geneva, 45:468-471,
operator possesses artistic for his ooiiaboration, and to Dr J. Amar- 10, Goodoore CJ. Gingivai esthetics. J
talent, using a ncvel wox-up Leonhordt for her heip in reviewing the ProsthetDent 1990:64:1-12,
technique with wax veneers monuscript. 11, Dzierzak J. Computer imoglng: its
(veneered woxup), practioai appiication. J Am Dent
Assoo 1991,122:41-44,
2, The diognostic effort is evclu-
ated in vivo with provisicnci References 12, Nathonson D, Dentai imaging by
computer: A iook at the tuture. J
restorotions that reproduce Am Dent Assoc 1991:122:45-46.
1. Yuodelis RA, Fauoher R. Provisionol
the shape of the waxup restorotions: An integroted approooh
and optimally simulate the to periodontics and restorotive den-
estfietic potential and func- tistry. Dent Ciin North Am 1980:24:
285-303,
tion of the planned final
2. Rieder CE. The roie ot operatory and
restorotion. The described
i a b o r a t o r y personnei in p a t i e n t
template serves as en in- esthetic oonsuitations. Dent Clin
valuable guide, particuiariy North Am 1989:33:275-284.
tor tooth preparations, fabri- 3. Rieder CE, The use of provisionai
cafion of post-and-cores, restorations to develop and achieve
esthetic expeototions. Int J Reriodont
and conditioning at the
Rest Dent 1989:9.122-139.
adjacent soft tissues. Natural
4. Magne P Magne M. Beiser U, Noturol
and easily modifiable provi- and restorative orol esthetios. Part 1 :
sional restorations can be Rotionale ond bosic strategies for
fabricoted with a stratifica- successful esthetic rehobilitotions. J
tion technique that invoives Esthet Dent 1993:5:161-173.

ditferent types and layers of 5. M o g n e R M o g n e M, Belser U.

Restauration des dents onterieures.
self-curing and photopoly-
Rev Mens Suisse Odontostomatoi
merizing acrylic resins (sand- 1993:103:318-324,
wich provisional restorations).
The technician's creative

Volume 16. Number 6,1996