Title

  Salutation*

  Name*
  Email*
  Country*
  City
  Please fill in all the fields marked with  (*)

                                                                                                                                      

Upper right 1                                                                                                                                                 2 Upper left
THERAPY  
DIAGNOSTIC  
International 18 17 16 15 14 13 12 11   21 22 23 24 25 26 27 28
USA 1 2 3 4 5 6 7 8   9 10 11 12 13 14 15 16
 
USA 32 31 30 29 28 27 26 25   24 23 22 21 20 19 18 17
International 48 47 46 45 44 43 42 41   31 32 33 34 35 36 37 38
DIAGNOSTIC  
THERAPY  
Lower right 4

3 Lower left

 

Please use the following abbreviations to fill out the form.
You can leave the Therapy fields blank if you do not know which teeth are supposed to be crowned or treated.
If you use more than one abbreviation pro field please  separate them with comma. E.g. Therapy: Root canal + filling + crown with ceramic facing: RC,F,CC or implant + zirconia crown: I,Z. E.g. Diagnostic: Bridge with 2 crowns and 2 pontics: c b b c
 
Diagnostic findings (only for the diagnostic fields)
means the status quo at the moment or the actual condition
of your teeth
 		 Therapy (to be used only in therapy fields) means the dental treatment or what would have to be done. If you are not sure of the treatment please leave the Therapy fields empty.
 
   
Missing tooth (not replaced yet) m   Full metall crown C
Already existing crown (also as part of a bridge) c   Metall crown with ceramic facing CC
Already existing bridge pontic b   Zirconia crown (metall free) Z
Already existing implant i   Full metall bridge pontic B
Missing tooth replaced with a removable denture e   Bridge pontic with ceramic facing BC
Badly damaged tooth needs to be extracted x   Zirconia pontic (metall free) BZ
      3/4 or partial crown PC
The dental chart is the other way around. This specifications are being given by the World Dental Federation.
Each patient’s mouth is divided into 4 quadrants: upper-right, upper-left, lower-left and lower-right.Left and right, as in all medicine notations, refer to the patient and not to the person visiting him/her. The quadrants are numbered from 1 to 4, in a clock-wise sense, starting from the upper-right.

E.g. you have a bridge in the lower right jaw and 4 crowns in the lower jaw in the front, teeth 34,35, 36 are missing, please fill the diagnostic fields like this:

48 47 46 45 44 43 42 41 | 31 32 33 34 35 36 37 38
      c   b   b   c       c   c      c   c       m  m m
 

     Inlay 1 surface Y
    Inlay 2 surfaces Y2
    Inlay 3 or more surfaces Y3
  Full metall telescopic crown T
  Veneered telescopic crown with facing TV
  Root canal RC
  Tooth coloured filling composite resin F
  Extraction X
  Implant (only surgery) I
  Veneer VE 

 

 

 

  

Your wish for the dental work:

 
     

What kind of alloy or material should be used for the dental work?

 

Zirconia (not suitable for telescopic crowns)
Full ceramics (e.g. Empress) suited for inlays, partial crowns and veneers

    
     

 

You can submit us your pictures, X-Rays or other documents like referral slips in digital form.
(PDF, jpeg, jpg, tif, bmp, doc, txt, rtf, zip are accepted)
 
File 1:

File 2:

File 3:

File 4:

File 5: 		If you would like to send us some more information or have any other comments please use the field below