Date
Due Date
Doctor's Name
License #
Doctor's Email Patient Name Gender M F Age
Goal of Final Case Close Diastema Lengthen teeth Change Shape Widen Buccal Corridor
Feminize Smile "Youthenize" Smile Move Midline Replace existing PFM's Other
Items Included with Case: Master Impression (Qty. ) Opposing Impression or Model Pre-operative Models Diagnostic Wax-up Bite Registration w/stick Bite registration w/o stick Facebow Transfer Jig (Manufacturer ) Model or Impression of Provisionals Matrix for determining buccal-lingual position of centrals Photos (Qty. ) Slides (Qty. ) Media Card (Qty. )
Teeth to Be Restored:
Type of Restoration: Feldspatic Pressed Ceramic Milled Ceramic Details:
Shade of Preparation: Core Shade Teeth #s ST
Shade (see below) Body Shade Gingival Shade Incisal Shade Occlusal Staining
Shape: Smile Design Handbook Smile Guide Design# Match photographs included Smile Catalog Design
Length: Centrals mm Laterals mm Canines mm Special Length Instructions:
Incisal Translucency: Minimal (0.5mm) Moderate (1.0mm) Maximum (1.5mm)
Shade of Translucency: Clear Smoke Frosted Amber
Surface Texture: High Medium Light Smooth (No surface texture)
Surface Finish: High Glaze Polished Gloss Satin Finish Low Gloss
Miscellaneous Info: