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


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