<p> 530 Hayward St, Ogdensburg, NY, 13669 1-888-250-7765 [email protected]</p><p>Dr’s Name Address Patient (print) Date required SET-UP INSTRUCTIONS SET UP OVERBITE □ Diagnostic Set-Up □ Ideal (1-2 mm) □ Other………... □ Full Set-Up: Reset all Teeth □ Partial Set-up: Mark Teeth on diagram OVERJET 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 □ Ideal (0mm) □ Other………... R L 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8</p><p>□ Gnathological Set-Up: SPACE CLOSURE ●SAM ●DENAR ●HANAU ●WHIPMIX □ Close All □ Compromise □ No Set-Up (Positioner only) □ Leave space between ………. □ Duplicate Models □ Remove Brackets ANTERIOR ROOT TORQUE UPPER: ARCH WIDTH □ Maintain □ Palatal…..□ Labial…… UPPER: □ Maintain □ Constrict □ Widen LOWER LOWER: □ Maintain □ Constrict □ Widen □ Maintain □ Palatal…..□ Labial……</p><p>LOWER OCCLUSAL PLANE POSITIONER BITE OPENING □ Flat □ Curve of Spee □ Other……….. □ Standard hinge axis □ Hinge Axis tracing enclosed ARCH FORM □ Gnathological Set-Up □ Normal □ Tapered □ Ovoid □ Same as Model MIDLINE WAX IN PONTICS: □ Maintain □ Align 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 □ Other (Please specify) R L 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 POSITIONER MATERIAL AND OPTIONS □ VINYL (Pressure Formed) POSITIONER THICKNESS Color: □ Normal □ Thick □ Thin □ Other… □ Clear □ Black □ Red □ Blue □ Green POSITIONER HEIGHT □ VARIFLEX® (THERMO-ACTIVE) (From gingival margin) For fine Finishing □ Normal (3mm) □ High (4-5mm) □ Short (1-2mm) □ Other……….. □ TALON® (THERMO-ACTIVE) For fine Finishing AIR HOLES □ No Air Holes □ Standard Air Holes FINISH POSITIONER DISTAL TO: □ Large Breathing Pathway 8 7 6 6 7 8 R L ADDITIONAL INSTRUCTION</p><p>8 7 6 6 7 8 □ PLEASE SEND POSITIONER Rx DR’S SIGNATURE:</p>