Crown & Bridge W.A.

- Dentist & Patient Information - Restoration Type

Zirconia Provisional
Today’s Date:
PFZ* (Porcelain Fused to Zirconia) PMMA Crown
PMMA Bridge
Due by:
(Standard working time if no date given)
FCZ (Full Contour Zirconia) Acetal Crown (long term material)
Acetal Bridge (long term material)
Dr. Name (Acetal shades: A1, A2, A3.5, B1, Bleach)

Dr. Phone All Ceramic (Lithium Disilicate) PFM Metal

Layered Crown* (recommended for single tooth anterior) High Nobel
Email Monolithic Crown (recommended for posterior) Noble
Layered Veneer Base Metal
Monolithic Veneer
Inlay/Onlay Full Contour Metal
Au 58%* Yellow (High Nobel)
Patient Hybrid-Ceramic Au 2% Warm Yellow (Nobel)
(REQUIRED) Crown Base Metal Silver Color
Veneer Vacuum formed template:
Inlay/Onlay o Implant
o Provisional restoration
Male Female o Bleaching tray
- Design - Specifications
Characterization COMMUNICATION
Shade:
Email Design Approval Yes No
Special Instructions
(REQUIRED)
Yes
Call me (Technical)
* Standard design if an option is not selected
Stump
Shade: Completion Complete*
(REQUIRED for Glass Try-In Framework
Ceramics or Esthetic Zirconia) Try-In Device
Wax Up (prior to starting case)
Tissue
Shade:
TECHNICAL

Pontic Design Occlusal Stain None* Light Medium

Limited Space Adjust opposing* Occlusal Island
Reduction Coping Call
Adjacent Contact Pin Point Firm
Light* Tight
Occlusal Clearance Just Out (16μ paper, no marks)
Supervisor Signature:
ridge-lap*
Modified

Sanitary /
ridge-lap

Hygienic

Conical

Light* (16μ paper, 1 dot)

Saddle

Ovate

(REQUIRED)