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