WWW.PANTHERADENTAL.COMTOLL FREE: 1 855 233-0388

RECOMMENDED

RECOMMENDED

RECOMMENDED

LOWER PLATE Check one

UPPER BAND Check one

LOWER BAND Check one

PRESCRIPTION

UPPER PLATE Check one

FULL

WIDTH

Central only

Lateral to lateral

Canine to canine

RECOMMENDED

CHECK TO USE OPTIMAL VALUES*

CUSTOMIZE SECTION

* If checked, do not �ll the Customize Section.

SIGNATURE

I want my D-SAD to be manufactured by Panthera Dental Inc.

Dentist: License #:

Address: City/State/ZIP:

Phone: Email:

Patient Name: Due Date:

Dental Prosthetic Services1900 51st Street NECedar Rapids, Iowa 52402Toll Free: 800-332-3341Fax: 319-393-8455www.DPSdental.com

PROTRUSIVE BITE

Bite represents maximum protrusion (100%)

Bite represents starting point

VERTICAL DIMENSION

Close as much as possible

Keep it, call if changes needed

LATERAL DEVIATION

None

Yes

_________mm left/right

BRUXISM

None

Light-moderate

Severe

ELASTICS

None

Yes

DISTAL WRAP

None

Yes

COVER THIRD MOLARS

No

Yes

ROD PREFERENCE

1mm increments

.5mm increments

Please indicate all restorations on

diagram.

1

3

2

4

56

7 8 9 1011

12

13

14

15

16

R L32

31

30

2928

272625 24 23

2221

20

19

18

17

STANDARD FULL ANTERIOR

STANDARD FULL ANTERIOR

SIMPLE BUCCAL 1/2 SIMPLE LINGUAL

1/2 SIMPLE LINGUAL FULLSIMPLE BUCCAL

NOTES: