Set-Up Instructions
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
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
R L
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
/
OVERJET
□ Ideal (0mm) □ Other………...
□ Gnathological Set-Up:●SAM ●DENAR ●HANAU ●WHIPMIX /
SPACE CLOSURE
□ 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……
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
R L
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8 /
□ Other (Please specify)
POSITIONER MATERIAL AND OPTIONS
□ VINYL (Pressure Formed) / /POSITIONER THICKNESS
Color: / □ Normal □ Thick □ Thin □ Other…□ Clear □ Black □ Red □ Blue □ Green
POSITIONER HEIGHT
(From gingival margin)□ VARIFLEX® (THERMO-ACTIVE)
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 HolesFINISH POSITIONER DISTAL TO:
/ □ Large Breathing Pathway8 7 6 6 7 8
R L
8 7 6 6 7 8
ADDITIONAL INSTRUCTION
□ PLEASE SEND POSITIONER Rx
/ /DR’S SIGNATURE: