accessibility ACCESSIBILITY
 
 Date:   Deliver to Clinic Date:
 Doctor:  License Number:  Phone Number:
 Address:
 City:  State: Zip code:
Patient Name:
Gender: Age:    

 



Tooth Number: 

Shade: 

Stump Shade: 


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


Items Included with Case
Master Impression Opposing Impression or Model  Diagnostic Wax-Up  Pre-Op Model 
Model of Provisional  Articulator Facebow Transfer Jib  Stick Bite 
Bite Registration  Photos  Photo Card  Flash Drive 
Analog  Impression Coping  Abutment  Final Screw 
Other:


Type of Restoration Desired

 Porcelain Fused to Metal (PFM)

 High Noble  Noble  Chrome Cobalt

 Full Gold Crown (FGC)

 High Noble  Noble

 e.Max - Monolithic  e.Max - Layered
 e.Max press over Zirconia  Porcelain Fused to Zirconia
 Prettau (Monolithic Zirconia / MZ)  PMMA Temporary (polymethyl methacrylate)
 Porcelain Butt Margin  Diagnostic Wax up
 Other:


Case Notes and Goals

 

Implant Restorations
 Screw Retained
 PFM  Layered Zirconia  e.Max press over Zirconia  Implant Temporary

 

 Cement Retained

 

 Custom Titanium Abutment
     Titanium Hue         Gold Hue

 Custom Zirconia Abutment
     Zirconia Connection         Metal Connection

   Custom Cast Gold Abutment
     Yellow High Nobel         Yellow Noble
 Other:

 

Milling Center Preferred 

 Group IV  Nobel Biocare  Atlantis  Straumann  3i  No Preference



If Inadequate Clearance
Provide Reduction Coping Reduce Prep without Reduction Coping  Reduce Opposing  Metal / Zirconia Island Please Call Doctor 



Return Case for
Die Trim Doctor Evaluation after Mounting Framework Try-in  Bisque Bake



Framework Design
Full Porcelain,
no metal
showing
Lingual
Shoulder
Lingual shoulder
with small labial
shoulder
Narrow shoulder
all around

Full metal
lingual

Full metal lingual
with narrow labial
shoulder

 

 

 

 

 Full Porcelain,
no metal
showing

Lingual
shoulder

Lingual shoulder
with small labial
shoulder

Lingual cusps
metal

Lingual cusps metal with
narrow buccal shoulder
Buccal porcelain veneer Buccal porcelain veneer
with narrow buccal
shoulder
Buccal porcelain veneer
with protected buccal
cusp





* Implants with zirconia connections will be manufactured by Nobel Biocare, Straumann, or Atlantis

**Implants with metal connections on zirconia abutments can be milled by Group IV or Nobel Biocare.

! Metal connections are cemented to the zirconia abutment in lab.

Pricing varies by manufacturer, most companies can produce platforms on their competitors, call us or consult your rep for more information.

Group IV warranties zirconia custom abutments for breakage or defects in workmanship for 5 years. No warranty is provided for the implant fixture itself. Some implant companies will negate their warranty on the implant if the abutment used is manufactured by a competitor, partner, or third party. Group IV assumes no responsibility for the implant fixture. Please consult your warranty information provided by the implant manufacturer.