LeValley Dental
860 S. 2nd Ste B.
Walla Walla, WA 99362
Phone: 1.509.522.1051
Fax: 1.509.522.1290
glevalley@charterinternet.com
Doctor's Name:

Due Date:

Patient Name:

Seat Date:
Gender: M F       Age:
Goals of the Final Case:
Teeth to Be Restored:
Type of Restoration:
 Pressed Ceramic  
Pressed to Metal
 Refractory
Sinfony®

Case Checklist:
 Master Impression
Opposing Impression or Model 
Pre-operative Models
Bite Registration
Stick Bite
Picture of Stick Bit
Stratos 200 Face Bow Transfer Jig
Impression of Provisionals
Pictures of Provisionals

Eyebrow to Chin Natural Smile (Not Numb)
Smile Profile

Pictures of Pre-operative Natural Smile

 
Stump Shade:   

#'s   St.
#'s   St.
#'s   St.

Body Shade
Gingival Shade
Incisal Shade
Occlusal Staining


Lenghts:
Centrals mm
Laterals mm
Canines mm

Gingival Recontouring:


Specific changes to be made from provisionals (e.g., midline, lenghts, incisal edge position, shpaes, occlusion, etc.):


Incisal Translucency: Midline  Moderate  Maximum
Shade of Translucency: Clear   Smoke  Frosted  Amber
Surface Texture : High  Medium  Light  Smooth
Surface Finish : High Glaze  Olished Glass  Satin  Low Gloss