Pantera Order Form

Case Identifier and Product Selection

Patient Name

Dental Practitioner Name

Clinic Name

Requestor Email

Requestor Contact Number

Panthera Classic

Panthera x3

Please mark each crown and/or pontic as well as fragile teeth

Mouse over tooth:

This Case has no Crowns, Pontics, or Fragile Teeth

Comments

1. Type of bite provided

Maximum protrusion bite

The appliance will be set at 60% of the bite position provided, to allow incremental forward movement up to the maximum protrusion bite provided

Starting point bite

The appliance will be set to start at the provided bite position, to allow incremental forward movement.

I will not provide a bite

2. Vertical spacing

Close or open to optimize the device

Keep it, call if major changes needed

3. Is mandibular protrusion straight

Yes

No

4. Other options

NEW! Elastics are now included with every X3.

Add a Panthera morning repositioner

Prefer upper splint distal wrap

Do not cover 3rd molar

Upper

Lower

Comments

Plateau

Use optimal values (Bio-Match)

Customized

Upper plateau

Lateral

Full

Lateral

Full

Band

Use optimal values (Bio-Match)

Customized