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ABOI/ID Part II Case Presentation – Template

+Case #

Type of Case:

+Implant Surgery

Date of Initial implant surgery:

Number of implants placed and where:

Did this case require pre-implant placement grafting of any

kind?

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Date of final prosthesis insertion

Type of restoration

Opposing dentition

Current status

+Patient Medical History

ASA Classification

Patient’s mental status

Relevant past/and current medical history

Medications

Allergies

+Dental History

Missing teeth

Periodontal status

Occlusion/ Angle Classification

+Pre-Surgical X-Ray (insert)

+Social History

Smoking

Alcohol

Drug/substance abuse

+Treatment Planning

Surgical Plan

+Prosthetic Plan

Prosthetic plan

+Informed Consent (insert)

+Alternative treatment plans discussed with patient Alternative treatments discussed:

+Implant Surgery

Operative report of actual implant surgery

+Post Surgical x-ray

+Post-Operative Care

What were your post-operative instructions for this patient?

+Maintenance

What is your maintenance protocol?

List this patients maintenance history

+Prosthetic Restoration

What type of restoration was placed?

Explain

+Immediate post prosthetic placement x-ray (insert)

+Occlusal view of maxillary arch (insert)

+Occlusal view of mandibular arch (insert)

+Frontal view in maximum intercuspation position (insert)

+Left side (insert)

+Right side (insert)

+For cases that involve implant supported/retained prostheses Insert views of all implant attachment mechanisms (intra-oral)

Views of tissue surface areas of the removable prostheses

(add slide if necessary)

+One year post prosthetic placement x-ray (insert)

+Revision (if necessary)

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