Crown & Bridge Form - Z Dental Laboratory

CROWN AND BRIDGE FORM

CROWN AND BRIDGE RX FORM

Please supply information following the form below. Note: All inputs have "*" as the required information.

Gender

M

F

Optional:

New Case

Redo Case

Update scaned files

CROWN INSTRUCTION

RESTORATION

Crown

Bridge

Design Only

TRANSLUCENCY

Low

Medium

High

FISSURE STAIN

None

Light

Normal

SHADE INSTRUCTION

POSITIONS

ADDITIONAL INSTRUCTIONS

PRODUCT OPTIONS

FULL PORCELAIN

Full Zirconia Crown

Full Zirconia multilayer

Zirconia Coping

Zirconia Layered

Full E.max Crown

E.max Veneer/Inlay/Onlay

FULL CAST METAL RESTORATION

Full Non-precious crown

Full Semi-precious crown

Full Gold

Casting abutment with semi precious

PORCELAIN FUSED TO METAL

Porcelain to Non-Precious

Metal Coping

Porcelain to Semi-Precious

Post & Core

Post & Core precious metal

Pro-V (Temporary Crown)

Add pink porcelain

Rest

3D PRINTER

3D print model (Partial/Arch)

3D print model (Full U-L)

EXTRA

Adapt crown to partial

Reduction coping

Pink porcelain

Porcelain margin 180*

Porcelain margin 360*

Jig for implant

Wing metal

Zirconia wing

PORCELAIN ON IMPLANT

Porcelain to Non-Metal on implant

Porcelain TiTan

Porcelain Chrome - Cobalt (Cr-Co)

Full Zirconia on implant

Zirconia layered on implant

E.max on implant

Restoration on Abutment (customize)

Adjusted Standard Abutment

Customized Standard Abutment

Customized Abutment (Titanium)

Customized Abutment (Zirconia)

Temporary teeth PMMA (CAD/CAM)

Screw Retain labor on Crown

Fixed Cement Retain labor

DESIGN REQUIREMENTS

PONTIC DESIGN

HYGIENIC

RIDGE LAP

MODIFIED RIDGE LAP

BULLET

OVATE

OCCLUSAL CONTACT

Heavy

Light

Open

INTERPROXIMAL CONTACT

Normal

Extended

EMBRASURE

Normal

Close

METAL DESIGN

0

1

2

3

4

5

6

ENCLOSE

SCANED FILES AND OTHERS

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LINK TO DOWNLOAD (Attach links below)

BITE IMPRESSIONS/TRAYS:

Pick up the bite impressions at my address

OTHERS ENCLOSE

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