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COMMENTS
IPS E.max® is a registered trademark of Ivoclar Vivadent, Inc.BruxZir® is a registered trademark of Glidewell Laboratories
Restoration Teeth Numbers Pontic Design
1
32
31
30
29
2827
26 25 2423
2221
20
19
18
17
2
3
45
67
8 910
1112
13
14
15
16
upper
lo w er
□
□
□
□
□BruxZir® Solid Zirconia
AESTHETIC GOALS: SIZE & FORM
TEETH SHADE TISSUE SHADE OPACITY
SURFACE-TEXTURE
Change ColorIncrease LengthClose SpacesCorrect AlignmentWiden Buccal Corridor
Total Length Of Central ____ mmLateral Incisal Edge:
Shorter By ____ mmSame Length Of Central
Desired Shade: ______Desired Body Shade:______Desired Incisal Shade:_____Stump Shade: ______Occlusional Staining:
None MediumLight Dark
MaximumMediumMinimumTranslucent
ClearLight PinkPinkMed MeharryDk Meharry
SmoothModerateHeavy
FIXED RESTORATIONS
Porcelain to MetalDesign□ 360° Metal Margin (__mm width)
□ Porcelain Butt Margin
□ No Metal Showing
□ Design For Future Partial
□ Metal Island
□ Metal Occlusal
□ Non-precious
□ Semi-precious__2% Gold
□ High Noble __52%__87%
□ Captek
Full Metal Crowns
Feedback Section- How’s The Fit?
□ Non-precious
□ Semi-precious __2% Yellow Gold
□ High Noble __52%__87%
Dr. Signature: Client agrees to all terms & conditions. Payment due upon receipt of statements.Unpaid balance subject to 1.5% monthly service charge.
License #:
Amount Of Prep Reduction: 1mm* 2mm
CADpro™ All-Ceramic Restorations
Check Here To ManufactureCeramics Or Full-Cast Using CAD/CAM
Please Scan And Save This CADpro™Case For Final Ceramic Work
CADpro™ Zirconia RestorationsIndicate Stump or Present Tooth Shade For All-Ceramics
CADpro™ MonoZrCADpro™ MonoZr+
CADpro™ Temps Provisional RestorationAbutment #(s) __________________ Pontic #(s)______________________
CADpro™ Removeable Appliances
CADpro™ Implant Restorations
CADpro™ DEFENSE MouthguardsCADpro™ Crystasis Retainers
Splinted*Individual Units
Reinforcement: None Fiber Metal
Cement-On ImplantsScrew-Retained Implant
ImplantsSystem ______________Brand________________Diameter_____________
IPS e.max CADMonoZrMonoZr+ProZr BridgeImplant Denture Bar
MonolithicCADpro™ IPS e.max® PressCADpro™ IPS e.max® CAD
TypeVeneerInlay/OnlayCrown
CutbackCADpro™ IPS e.max® Press+CADpro™ IPS e.max® CAD+
ENCLOSED WITH CASE PLEASE RETURNCastingFor Solder ConnectionAssembled Framework
Bisque BakeGlaze
ImpressionsModelsBite
PhotosOther
TitaniumZirconia HybridAll Zirconia
Custom Abutments Screw-Retained
CADpro™ Occusal SplintsCADpro™ Custom Trays
Occlusal anatomy◌ I like the CADpro™ restoration you sent to me◌ I like deep pits and fissures with prominent cusp formation◌ I like a flat occlusal anatomy with shallower cusp formation
Fit◌ I like the fit of the CADpro™ restoration you sent me◌ I prefer a smaller cement gap with a tighter fit◌ I prefer larger cement gap ensuring units will “fall in” easily
Contacts◌ I like the contacts of the CADpro™ restoration you sent me◌ I prefer tighter contacts◌ I prefer looser contactsParts Provided? Yes No
®
370 Crossways Park Drive P: 516.466.1722| F: 516.466.1261www.JurimDental.com
Dr/Practice: Address: Phone:
Patient Name: □ Please call before proceeding with case □ RedoRx Date: Due Date: □ Previous Case #
112017
