CusDeLa
Custom Dental Laboratory
4201 Sanderson Lane , Texarkana. AR. 71854
For Pick up and Delivery, Please Call
Office: 870-779-9490 Cell: 903-490-9310
Hours: Mon - Fri: 8am - 5pm Sat: As request
w.w.w.cusdela.com Email:
DOCTOR NAME:: _____________________________________ DATE: _____________ RETURN DATE: ________________
PATIENT NAME: __________________________________________ PATIENT AGE: _________ Female _____ male: _____
Full Metal Cast: PFM :
O. Non Precious O. Non - Precious
O. 2% Noble Yellow or White O. Noble White
O. HN - White, 40% Au O. HN - White
O. HN - Yellow, 55.8% Au O. HN - Yellow
O. IPS e.Max ZirCAD Milling
Zirconia :
O. KATANA Multi Layer: 4 Layer structure, For Anterior, Posterior Full contour(1-3 Units) O. BruxZir 16: for Anterior, Posterior. Matching 16 ViTa Shade, 1050MPa
O. Hi - Strength Full Contour Zirconia Bridge: (40-45% Translucent, up to 1250 MPa). Beautiful Enough for the Anterior & Strong Enough for Full Arch
O. PFZ ( Porcelain fuse to Zirconia).
Temporary, PMMA : O. Shaded O. Multi-Layer
Restoration : O. Inlay / Onlay O. Veneer
O. Crown O. Bridge
Ceramic Margin: O. Facial 180
Rest: O. Mesial O. Distal
Pontic Design: O. Modified Ridge Lap O. Ovate
O. Full Ridge La p O. Sanitary
Implant :
O. Implant Brand_______________________________________
O. Abutment material Choice:
a/ Titanium___________________
c/ Zirconia____________________
e/ Full Contour Screw Retained_______________________
O. Emergence with options:
a/ Full Anatomical dimensions ______________________
b/ Contour follow soft Tissue _______________________
c/ Support soft Tissue ______________________________
d/No Tissue displacement __________________________
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17
Shade Instructions:
Shade
______
Stump
______
Occlusal Staining: O. None O. Light O. Medium O. Dark
Occlusal Contact: O. Light O. Open O. Tight
Contact & Embrasures: O. Broad O. Light O. Tight
Rx * Please provide any photos and study model on all Anterior.
Special Instructions:
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Dentist Signature: ______________________________________________________________
License # : ______________________________________________________________________