ICOI Diplomat Candidate Case Documentation Form (Minimum 5 Years Old)
Name: Xin Wei (XW), DDS, MS, PhD Date: 7/11/2015
Pt's Initials | Max/Mand Arch | Date Implant(s) Placed | Type of Implant | Implant Surgical Dentist | Ancillary Procedures | Date Restored | Type of Restoration | Dental Lab | Current Status | |
1 | LH | #19 | 04/18/2006 | RF | XW | ABG | 04/22/2008 | SCR | Bicon | SF |
2-4 | VH | #28-30 | 09/13/2006 | RF | XW | ABG | 09/07/2007 | SCR | Bicon | SF |
5 | DT | #30 | 07/09/2008 | RF | XW | ABG | 02/17/2009 | SCR | Local | SF |
6 | YH | #30 | 08/11/2008 | RF | XW | ABG | 06/26/2009 | SCR | Bicon | SF |
7-10 | YH | #2-4 | 10/24/2008 | RF | XW | ABG | 12/02/2009 | FBR | Local | SF |
11 | ZC | #4 | 09/02/2009 | RF | XW | ABG | 03/16/2010 | SCR | Local | SF |
12 | SY | #14 | 09/28/2009 | RF | XW | ABG | 05/08/2010 | SCR | Bicon | SF |
Coding
Type of Implant | Ancillary Procedure(s) | Type of Restoration | Current Status |
Root form—RF | Guided tissue grafts—GTR | Single crown—SCR | Satisfactory function—SF |
Small diameter—SD | Autogenous bone grafts—ABG | Fixed bridge—FBR | Compromised function—CF |
Plate form—PF | Sinus augmentation—SA | Overdenture—OD | Failed & removed—FR |
Subperiosteal—SP | Soft tissue grafts—STG | Partial overdenture—POD | lost to recall—LR |
Allograft bone grafts—ALG | Fixed-detachable prosthesis—FDP | ||
Alloplast bone grafts—APG | |||
Cone Beam Cat Scan—CBCT |
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Xin Wei, DDS, PhD, MS 1st edition 07/06/2013, last revision 07/12/2015