Clear Image® Aligners Rx Guardian® Invisible Retainers Rx

DR. SIGNATURE: LICENSE NUMBER:

1-17

P.O. BOX 100005, CUMMING, GA 30028-9919 (FOR USE ONLY WITH SPECIALTY APPLIANCES PREPAID BUSINESS REPLY LABELS)4905 HAMMOND INDUSTRIAL DRIVE, CUMMING, GA 30041 (FOR ALL CASES SHIPPED DIRECTLY TO STREET ADDRESS)

(800) 522-4636 • IN GEORGIA (678) 513-4408 • FAX (678)513-7345 • SPECIALTYAPPLIANCES.COM

OFFICE USE: 1 2 3 4 + PD: SA DRMODELS: U L BOTH BANDS CROWNS BROKENIMPRESSIONS: U L BOTHDISINFECT:______ QA IN:______ FINAL INSP:______

IPR INSTRUCTIONS FOR RESETS

Reduce Teeth as Needed in Laboratory IPR Done Clinically Prior to Impressions No IPR Required

FIXED LINGUAL RETAINERSPlacement of Retainer Upper LowerCentral – Central Lateral – Lateral Cuspid – Cuspid

Composite Pad Design Pads on Each Tooth Pads on Distal Most Teeth Mesh Pads on Each Tooth Mesh Pads on Distal Most Teeth AOB Pad Design

Type of Wire Round .028 .016 – .022 Braided .016 – .022 Solid SS

GUARDIAN® INVISIBLE RETAINERS REQUESTED

2 IR's 3 IR's 4 IR's 2 IR's 3 IR's 4 IR's

Reset Anterior Teeth (2–2) – Indicate on Diagram Above Add Fixed Lingual Retainers – Indicat Add Pon cate on Diagram Shade __________________

CLEAR IMAGE® ALIGNER SERIES REQUESTED

Series 1 – 3 Aligners as Needed Upper Lower

Series 5 Aligners Upper Lower

Specialty Invisible Retainers Upper Lower

Circle Teeth to Reset/Check Teeth to be Overcorrected

R7 6 5 4 3 2 1 1 2 3 4 5 6 7

L7 6 5 4 3 2 1 1 2 3 4 5 6 7

EXPIRES:

DATE SHIPPED DATE NEEDED

AS SEND ADDITIONAL

ACCT#

/s/

Digital Scan Taken with:

iTero®3Shape3M®

Carestream®Sirona®

SPECIAL INSTRUCTIONS

Add Mouthguard (Upper Only) - Select Color Below

Black White Blue Red Green

GUARDIAN® OPTIONS

Upper ArchLower Arch

Pre - GUARDIAN® Upper Arch Lower Arch

11-14

CLEAR IMAGE® ALIGNERS – SERIES REQUESTED – DEFINITION OF SPECIALTY ALIGNER PRODUCTS

Series 1-3 Aligners as NeededThis product is used for the simplest aligner cases where only 1-3 aligners are needed. The Series 3 aligners can be used for either arch or both arches together.

Series 5 AlignersSeries 5 aligners can also be used for either arch and are used when moderate changes are required. These aligners are effective in correcting rotations and lingual/labial movements and typically involve IPR to gain space in the anterior area for corrections.

Circle Teeth to be Reset/Check Teeth to OvercorrectedThe diagram provided allows the clinician to select individual or groups of teeth for corrections by marking the diagram accordingly. Please consider the need for over-corrections with rotations when using aligners.

IPR Instructions for Resets – Use DiagramMost Clear Image® Aligners require IPR to help create space for the teeth to move. On this diagram, please indicate the location and amounts of IPR or check that IPR has been done prior to taking impressions/scans, or that No IPR is required.

GUARDIAN® INVISIBLE RETAINERS

GUARDIAN® Retainers are processed from your models, impressions or scans. Whichever type of record we receive, we will produce a scan and corresponding printed model for laboratory fabrication.

GUARDIAN® Retainers are available in any quantity requested – up to 4 appliances per arch fabricated at one time. All GUARDIAN® Retainers are processed on printed plastic models for maximum accuracy. These models are returned with all GUARDIAN® Retainers to give your practice the option to fabricate replacement retainers as needed. We use .040 Essix® Clear for all GUARDIAN® Retainers as this is known industry wide as the "standard" for clarity and durability.

GUARDIAN® Enhancements

Remove BracketsWe routinely remove brackets on all GUARDIAN® cases unless requested otherwise. Using the latest in advanced software, all fixed appliances are removed free of charge at the scanning stage to be reflected in the printed model.

Reset Anterior TeethA clear advantage with the GUARDIAN® program is our ability to reset anterior teeth prior to printing the plastic models and making the appliances. First, you will receive an Aligner to provide flex to reposition the teeth (centrals and laterals only), followed by appliances 2-4 which maintain the corrections using a slightly thicker material. Please indicate on the diagram which teeth are to be reset on each arch.

Add Fixed Lingual Retainer to a GUARDIAN® SeriesSpecialty will build a Fixed Lingual Retainer design of your choice and then process the GUARDIAN® Retainers to fit over the Bonded Retainers. The FLR is delivered at the same appointment the braces are removed with the GUARDIAN® Retainers fitting precisely over the Bonded Retainers. Several designs of FLR's are available – please use the diagram to indicate your wire and pad preferences.

Add Pontics to GUARDIAN® RetainersAs an enhancement to aesthetic retention, pontics can be added to any GUARDIAN® Retainer. We can also add fixed pontics to any FLR design as a semi-permanent solution for patients too young for implants or restorations. We encourage practices to contact our customer service representatives for additional information regarding these options.

We recommend that all wires and bands are removed prior to submitting impressions to Specialty. If wires orbands are present on submitted models, it may result in an additional per arch charge to remove them in the lab.