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Get MI MSA-1680-B 2012

T Plan Enclosed? No Yes / 22. Indicate: Missing Teeth with an “X” - Teeth to Be Extracted with a " / ". 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 / A B C D E F G H I J T S R Q P O N M L K 27 26 25 24 23 21 20 16 20. Is this Initial Placement of Prosthesis? No Yes Max. 32 31 30 Mand. 29 21. Status of Current Prosthesis: Part Full 22 19 18 17 EXAMINATION AND TREATMENT RECORD Can Be Date Inserted 28 Worn Yes No Repaired Yes No Used Now Yes No L I .

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