Patient Information:
Name: John Doe
Date of Consultation: October 15, 2023
Referring Dentist: Dr. Emily Smith, Smile Dental Clinic
Reason for Referral: Root fractures and missing teeth
Clinical Findings:
Tooth Condition:
Teeth Affected: 14, 15, 16
Current Condition:
Tooth 14: Confirmed root fracture, extraction recommended
Tooth 15: Insufficient bone, requires extraction
Tooth 16: Broken root, no pain
Existing Gaps: Gaps in the upper right arch after extractions
Diagnostic Imaging:
X-rays/CT: Insufficient bone at site 15, sinus proximity noted
Bone Quality: 5 mm bone depth at the implant site
Treatment Plan:
Extractions:
Teeth to be Extracted: 14, 15
Planned Implant Sites: 14, 15
Implant Placement:
Number of Implants: 2 implants
Site Details:
Implant #1 in position 14
Implant #2 in position 15
Sinus Lift Required: Yes, Summer's Osteotomy will be used
Expected Healing Time: 4 months for bone integration
Post-healing Restoration: Referring dentist to place crowns.
Special Considerations:
Bone grafting: Yes, human allograft
Possible complications: Difficulty due to sinus proximity
Medical History:
Heart Conditions: None
Diabetes: Controlled, HbA1c at 6.5%
Hypertension: Medicated, monitored weekly
Lifestyle/Exercise Tolerance: Active lifestyle with regular outdoor work
Patient Preferences:
Sedation Preference: Yes, intravenous sedation
Crown/Bridge Preferences: Prefers implants over bridges, crown restoration plan
Cost Estimate Provided: Yes, approximate cost discussed
Follow-up:
Next Steps: Surgery scheduled for implant placement, referral to dentist for crowns, patient to confirm final treatment plan
Post-op Care: Prescription provided, post-op instructions
Surgeon’s Recommendations:
Final Implant Decision: Proceed with two implants at sites 14 and 15
Additional Notes: Consideration for bridge if implant fails, long-term prognosis of implants is favorable
