DIAGNOSTIC WAX UP INSTRUCTIONS

This form has been created to aid us in working as a team to create an ideal functional and
esthetic diagnostic blueprint for this patient.

Patient’s Name ________________________________ Age _________________________

Date Sent______________________________ Case Due Back ______________________
Dental Lab__________________________________________________________________

GOALS OF THE FINAL CASE

 Change Incisal Edge Position __________________________________________
 Change Tooth Shape ________________________________________________
 Change Tooth Shade ________________________________________________
 Close Diastema _____________________________________________________
 Crowding __________________________________________________________
 Change Gingival Levels_______________________________________________
 Alter Midline________________________________________________________
 Other _____________________________________________________________

OVERALL SMILE DESIGN

Description of Patient’s Desires__________________________________________________
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RESTORATION TYPE
Total # of teeth to be restored ________________________________tooth #s ____________
 Veneers____________________________________________________________
 Onlay Veneers_______________________________________________________
 Crowns ____________________________________________________________
 Onlays_____________________________________________________________
 Implants____________________________________________________________
 Bridge _____________________________________________________________
 Other ______________________________________________________________

Additional Comments _________________________________________________________

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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 DIFFERENT SMILE DESIGN OPTIONS
SQUARE

SQUARE ROUND

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 DIFFERENT SMILE DESIGN OPTIONS
ROUNDED

TRIANGULAR

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DETAILED TOOTH POSITION
Maxillary Central Incisors: Ideal Length ____ mm Width____ mm Shape_________________
Comments __________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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Maxillary Incisal Edge Position:

Vertical Position:  Acceptable  Alteration Planned
Shorten Teeth #s: _________________ amount___________ mm
Lengthen Teeth #s: ________________ amount___________ mm
Horizontal Position:  Acceptable  Alteration Planned
Labially position teeth #s:____________ amount___________ mm
Lingually position teeth #s:___________ amount___________ mm

Comments __________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Mandibular Incisal Edge Position:

Vertical Position:  Acceptable  Alteration Planned
Shorten Teeth #s: ______________________amount___________ mm
Lengthen Teeth #s: _____________________amount___________ mm
Horizontal Position:  Acceptable  Alteration Planned
Labially position teeth #s: _________________amount___________ mm
Lingually position teeth #s _________________amount___________ mm

Comments __________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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GINGIVAL TISSUE LEVELS

 Acceptable  Alteration Planned
tooth # _____ raise/lower _____ mm tooth # _____ raise/lower _____ mm
tooth # _____ raise/lower _____ mm tooth # _____ raise/lower _____ mm
tooth # _____ raise/lower _____ mm tooth # _____ raise/lower _____ mm

Comments __________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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OCCLUSAL FUNCTION
 Models are mounted in CR and have been trial-equilibrated
 Models are mounted in CR and have NOT been trial-equilibrated
 Models are mounted in MI/CO
 Models are unmounted

Comments __________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Occlusal Vertical Dimension

 Keep the Vertical Dimension the same as MI/CO

 Open the Vertical Dimension to the PIC (point of initial contact)
 Open the Vertical Dimension less than the PIC (point of initial contact)
 Open the Vertical Dimension beyond the PIC (point of initial contact)

Comments __________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
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Anterior Guidance
 same_______________________________________________________________
 steeper______________________________________________________________
 flatter_______________________________________________________________
 cuspid rise___________________________________________________________
 anterior group function - which teeth ______________________________________
 other _______________________________________________________________

Comments __________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Additional Case Information

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___________________________________________________________________________
___________________________________________________________________________
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Please note: Please provide a high quality duplicate model of the wax-up in high quality vacuum-
mixed die stone. We do not require a stent or putty matrix of this duplicate model.

Doctor’s Signature ______________________________ Date _________________________

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