Implant consultation template

Patient Information

• Name: Sipho Ndlovu
• Date of Consultation: 14/05/2024
• Referring Dentist: Dr. Annelize van der Merwe, Sandton Dental Studio
• Reason for Referral: Vertical root fractures and failed restorations in the UL quadrant

Clinical Findings

Tooth Condition

• Teeth Affected: 25, 26, 27

Current Condition

• Tooth 25: Retained root with subgingival caries, asymptomatic
• Tooth 26: Missing (extracted 3 years ago), edentulous ridge resorbed
• Tooth 27: Confirmed vertical root fracture with localized periodontal pocketing; extraction advised
• Existing Gaps: Edentulous space at 26 in the upper-left arch

Diagnostic Imaging

• X-rays/CT: CBCT shows pneumatization of the left maxillary sinus and periapical radiolucency at 27
• Bone Quality: Type III bone; 9 mm height at 25, 5 mm residual ridge height at 26 and 27

Treatment Plan

Extractions

• Teeth to be Extracted: 25, 27
• Planned Implant Sites: 25, 27

Implant Placement

• Number of Implants: 2 implants

Site Details

• Implant #1, #2 in position 25, 27.
• Sinus Lift Required: Yes; Summer's Osteotomy to be used at site 27
• Expected Healing Time: 4 months for osseointegration
• Post-healing Restoration: Referring dentist to place crowns.

Special Considerations

• Bone grafting: Yes; bovine bone (Bio-Oss®) xenograft planned simultaneously with transcrestal sinus lift
• Possible complications: Risk of Schneiderian membrane perforation due to sinus proximity at 27; delayed healing secondary to T2DM

Medical History

• Heart Conditions: Mild mitral valve regurgitation (no antibiotic prophylaxis required per current guidelines)
• Diabetes: Controlled T2DM on metformin 850 mg PO BID; recent HbA1c 6.7 %
• Hypertension: Controlled on amlodipine 5 mg PO OD; BP 128/82 mmHg today
• Lifestyle/Exercise Tolerance: Active lifestyle, walks 5 km daily, non-smoker, good exercise tolerance (> 4 METs)

Patient Preferences

• Sedation Preference: No; local anaesthesia only (articaine 4 % with adrenaline 1:100,000)
• Crown/Bridge Preferences: Prefers a 3-unit implant-supported zirconia bridge (25 to 27) to avoid extensive lateral window sinus grafting at 26
• Cost Estimate Provided: Yes; approximate cost of R 38,500 discussed for extractions, grafting, and surgical placement

Follow-up

• Next Steps: Patient to confirm final treatment plan; surgery to be scheduled for atraumatic extractions and immediate/delayed implant placement
• Post-op Care: Prescriptions supplied for amoxicillin 500 mg PO TID for 5 days, ibuprofen 400 mg PO TID PRN, and chlorhexidine gluconate 0.2 % mouthwash 10 mL BID; sinus precautions provided

Surgeon’s Recommendations

• Final Implant Decision: Proceed with extractions and two implants at sites 25 and 27 to support a 3-unit bridge
• Additional Notes: Good long-term prognosis expected given well-controlled glycaemic index and non-smoking status; removable partial denture discussed as an alternative but declined by patient