panthera dsad rx - edmonds dental prosthetics, inc. · toll free: 1 855 233˜0388 recommended...
TRANSCRIPT
WWW.PANTHERADENTAL.COMTOLL FREE: 1 855 233-0388
RECOMMENDED
RECOMMENDED
RECOMMENDED
LOWER PLATE Check one
UPPER BAND Check one
LOWER BAND Check one
PRESCRIPTION
UPPER PLATE Check one
FULL
WIDTH
Central only
Lateral to lateral
Canine to canine
RECOMMENDED
CHECK TO USE OPTIMAL VALUES*
CUSTOMIZE SECTION
* If checked, do not �ll the Customize Section.
SIGNATURE
I want my D-SAD to be manufactured by Panthera Dental Inc.
Dentist: License #:
Address: City/State/ZIP:
Phone: Email:
Patient Name: Due Date:
Edmonds Dental Prosthetics 2065 W Woodland St Springfield MO 65807800-462-3569 www.EdmondsDentalProsthetics.com
PROTRUSIVE BITE
Bite represents maximum protrusion (100%)
Bite represents starting point
VERTICAL DIMENSION
Close as much as possible
Keep it, call if changes needed
LATERAL DEVIATION
None
Yes
_________mm left/right
BRUXISM
None
Light-moderate
Severe
ELASTICS
None
Yes
DISTAL WRAP
None
Yes
COVER THIRD MOLARS
No
Yes
ROD PREFERENCE
1mm increments
.5mm increments
Please indicate all restorations on
diagram.
1
3
2
4
56
7 8 9 1011
12
13
14
15
16
R L32
31
30
2928
272625 24 23
2221
20
19
18
17
STANDARD FULL ANTERIOR
STANDARD FULL ANTERIOR
SIMPLE BUCCAL 1/2 SIMPLE LINGUAL
1/2 SIMPLE LINGUAL FULLSIMPLE BUCCAL
NOTES: