LAB INTERNAL ID: Date: Date of Arrival to lab Patient : GLOBAL QUALITY LAB A A2 Tandläkare: Female Tel: Male Shade/färg/farve: Age Try in, date: D Kund / Client nr Next visit, date: C Desinfekterat, Remake case signatur: Signatur: Crowns/bridges/etc Kronor/broar/etc Krone/Bro/etc Crown/Krona/Krone Bridge/Bro/Bro Material/Material/Material Post/Pelare/ Støbt opbygning Maryland/Etsbro/Ætsbro Inlay/onlay Temp.crown Co-Cr Titan Au 54% Au 75% Au 86% Pd 52% E-max Zirkonium Composite Metal/Composite Fiberreinforced Extras/Extra/Extra Margin porcelain/Skulderporslin/Skulderporcelæn Pink porcelain/Rosa porslin/Rosa porcelæn Full cast crown High esthetics (+50%) Split post/delad pelare/delt opbygning Parapost__________________ Telescope, outer Telescope, inner Richmondcrown Implants/ Implantat/ Implantat Single/partial 10+ teeth (full jaw) Number of fixtures__________ Implant system:________________________________________________ Type/Typ/Typ Screwed Cemented Material/Material/Material Co-Cr Titan Overdenture/täckprotes/tryklåse Au Cast partials/ Skeletterad protes/ Unitor Co-Cr Titan Lingual bar Teeth/Tänder/tænder Zirkonium Clasp/Klammer/klammer Lingual skena Ceramic Gold/guld/guld Acrylic Composite Steel/Stål/Stål No. of teeth:_______ Acrylic partials/ Oskeletterad protes/Akrylprotes 1-3 teeth 4+ teeth Immediate( no try in) Valplast, 1-3 teeth Valplast, 4+ teeth No. of teeth:_______ Full denture/helprotes/helprotese Upper/överkäke/overkæbe Extras/extra/extra Attachment Lower/underkäke/underkæbe Immediate (no try in) Individual tray/Individuell sked/Individuel ske Repair/lagning/lapning Add teeth/tillsättning/tilføje Bite block/bitschablon/plastron Relining/rebasering/rebasering Other/annat/ævrigt________________________________________________________ Splints/skenor/skinne Hard/hård/hård Semihard/semihård/semihård Soft/mjuk/blød Bleach/blekning/blege Prophylactic/profylax/profylax Basic (1 layer/lager/lager) Medium (2 layer f ex karate) Heavy (3 layer for ex. hockey) Mouthgard/sportskydd/tandbeskytter Antisnoring device/snarkskena/snorkeskinne Monoblock, hard/hård/hard Monoblock, semihard/semihård/semihård Design and instructions Please mark the teeth in construction. Pontic Monoblock, soft/mjuk/blød Biblock, hard/hård/hård 4+ 14 +4 24 3+ 2+ 13 12 1+ 11 +1 21 +2 +3 22 23 Hängande/ svæve Upper Fast Pontic Hängande/ svæve Fast Pontics Transparency 44 4- 43 42 41 3- 2- 1- 31 32 33 -1 -2 -3 Surface texture Occlusion stain Bullet High Heavy Heavy Medium Medium Medium Ovate Minimum Light Light None Deep ovate Half Ridge Lap 34 -4 Glaze Lower None Contact surfaces Low Glaze Hard Medium Glaze Medium High Glaze Loose Full Ridge Lap If insufficient space/Vid platsbrist: No contact Ok to grind/ok att slipa/ok att slipa Preparation Opposite Both Call dentist/ring för besked/ring! Instructions to lab: GQL - blå, Box 21078, 200 21 Malmö, tel. +46 40 914850 www.gql.se, email: [email protected] LAB INTERNAL NOTES: Metal Design Erkodent
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