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ABOI/ID Part II Case Presentation – Template
2013
+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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